A conversion I once had with a resident during lunch:
Resident: "I don't have any calls for the next, like, two weeks."
Me: "Who's on call tonight, by the way?"
Resident: "I don't know."
Me: (checks schedule) "Hey, YOU are!"
Resident: "I am???"
Me: "Uh, yeah. Good thing I looked it up, huh?"
An R4 at the table: "Well, it's not like it's important to know when you're on call. You'd probably figure it out eventually."
Tuesday, May 31, 2011
Sunday, May 29, 2011
Tales From Intern Year: Scooter Boy
Midway through my intern year, one of the interns named Ryan who had previously been ambulatory suddenly started zipping around the hospital on a mobility scooter. It was quite the spectacle. I finally ran into him in the resident lounge and I had to ask: "Why are you using a scooter??"
He looked at me and sighed really loudly, "Because the hospital was out of wheelchairs."
"Huh?" I said.
"This is the ninth time someone asked me that today. I should just make up cards to pass out with an explanation, shouldn't I?" he said.
"Or you could just tell me?" I suggested.
"Knee surgery," he said. "I got into a motorcycle accident."
"So where did the scooter come from?"
"The hospital gave it to me so that I could still do my job," he explained, punctuating it with a sigh.
Maybe he should have just made up a card with an explanation.... would have been a lot less painful than trying to drag it out of him. I mean, you can't start zipping around the hospital in a scooter without expecting to generate a few questions.
He looked at me and sighed really loudly, "Because the hospital was out of wheelchairs."
"Huh?" I said.
"This is the ninth time someone asked me that today. I should just make up cards to pass out with an explanation, shouldn't I?" he said.
"Or you could just tell me?" I suggested.
"Knee surgery," he said. "I got into a motorcycle accident."
"So where did the scooter come from?"
"The hospital gave it to me so that I could still do my job," he explained, punctuating it with a sigh.
Maybe he should have just made up a card with an explanation.... would have been a lot less painful than trying to drag it out of him. I mean, you can't start zipping around the hospital in a scooter without expecting to generate a few questions.
Saturday, May 28, 2011
Weekly Whine: Old "Friends"
So picture this:
You get a Facebook message from an old friend (more like a good acquaintance) who you haven't seen in close to ten years. It's a short message, briefly updating me on his life, saying that he ran into a mutual friend and they were wondering how I was.
You are pleased by the unexpected communication, tell him what you're up to, and ask the friend more questions about himself.
He replies, mostly telling you about his start-up company. And by the way, he adds, there's a company he's interested in investing in with a healthcare background. Might I be able to give him some feedback on the company and possibly covest/syndicate him?
What do you do?
a) Politely decline
b) Feel pissed off that he pretended to be interested in your life, but was actually using you
c) Ignore email entirely
d) Look at the company and possibly invest
e) Look up what "covest/syndicate" means
Right now, I'm going for a combination for b and c (and e). OK, admittedly, I have emailed or called someone out of the blue and pretended to be interested in reconnecting, when I was mostly in need of a favor. But that doesn't make it any less annoying.
You get a Facebook message from an old friend (more like a good acquaintance) who you haven't seen in close to ten years. It's a short message, briefly updating me on his life, saying that he ran into a mutual friend and they were wondering how I was.
You are pleased by the unexpected communication, tell him what you're up to, and ask the friend more questions about himself.
He replies, mostly telling you about his start-up company. And by the way, he adds, there's a company he's interested in investing in with a healthcare background. Might I be able to give him some feedback on the company and possibly covest/syndicate him?
What do you do?
a) Politely decline
b) Feel pissed off that he pretended to be interested in your life, but was actually using you
c) Ignore email entirely
d) Look at the company and possibly invest
e) Look up what "covest/syndicate" means
Right now, I'm going for a combination for b and c (and e). OK, admittedly, I have emailed or called someone out of the blue and pretended to be interested in reconnecting, when I was mostly in need of a favor. But that doesn't make it any less annoying.
Friday, May 27, 2011
90 Second Rule
Any med student or doctor who's ever seen a patient knows that patients can talk a lot. As a physician, a necessary skill is learning to redirect patients and get them to actually answer your questions, rather than telling you about the time they went to Morganville for a new heel for their shoe with an onion tied to their belt (which was the style at the time). I see about twenty patients a day, so if I let them all tell their stories every day, I'd have to basically just live at the hospital.
In residency, there were a few residents who just didn't seem to get the hang of redirecting patients. Whenever they'd go into the examining room of a talkative patient, they'd inevitably need a "rescue page" or else we'd never see them again. Whatever else could be said about me, I have never ever required a rescue page. I am excellent at rudely interrupting patients and getting answers out of them.
As an intern, we got a lecture about how Interrupting Patients is Bad. About how doctors interrupt patients too damn much and we miss out on information. The lecturer said that there was some study where doctors were actually observed talking to patients, and the longest a patient EVER went on for without being interrupted, like the World's Record, was 90 seconds. So really, you shouldn't interrupt your patients because they're not going to talk longer than 90 seconds.
What is wrong with this advice?
Well, if you have multiple questions you need to ask the patient, allowing them to go on for about 2 minutes per question, sometimes without actually even answering the question you asked, takes for freaking ever. So patients must be redirected. That said, the 90 seconds thing ACTUALLY WORKS. This is when it is useful:
Say you are done seeing a patient. They have answered all your questions and you have done everything you can for them. Or it is the weekend, they're stable, and basically, they just want to ramble on for a while... except you have 50 other patients to round on and you're starting to panic that you won't be able to escape without being rude. What you do is: you let them talk. You just stand there, smile, and do not say a word. Do not prompt them in any way. Don't even say "uh huh." Just smile politely. You can probably nod, but it's better if you don't. After about 90 seconds or usually less, they WILL stop talking. And when they do, you bid them farewell and quickly get the hell out of there.
This has worked for me many times. I did it a few days ago with a woman who honestly seemed like she would never ever run out of steam talking about god knows what, but sure enough, she fizzled out after about a minute. Just try it.
In residency, there were a few residents who just didn't seem to get the hang of redirecting patients. Whenever they'd go into the examining room of a talkative patient, they'd inevitably need a "rescue page" or else we'd never see them again. Whatever else could be said about me, I have never ever required a rescue page. I am excellent at rudely interrupting patients and getting answers out of them.
As an intern, we got a lecture about how Interrupting Patients is Bad. About how doctors interrupt patients too damn much and we miss out on information. The lecturer said that there was some study where doctors were actually observed talking to patients, and the longest a patient EVER went on for without being interrupted, like the World's Record, was 90 seconds. So really, you shouldn't interrupt your patients because they're not going to talk longer than 90 seconds.
What is wrong with this advice?
Well, if you have multiple questions you need to ask the patient, allowing them to go on for about 2 minutes per question, sometimes without actually even answering the question you asked, takes for freaking ever. So patients must be redirected. That said, the 90 seconds thing ACTUALLY WORKS. This is when it is useful:
Say you are done seeing a patient. They have answered all your questions and you have done everything you can for them. Or it is the weekend, they're stable, and basically, they just want to ramble on for a while... except you have 50 other patients to round on and you're starting to panic that you won't be able to escape without being rude. What you do is: you let them talk. You just stand there, smile, and do not say a word. Do not prompt them in any way. Don't even say "uh huh." Just smile politely. You can probably nod, but it's better if you don't. After about 90 seconds or usually less, they WILL stop talking. And when they do, you bid them farewell and quickly get the hell out of there.
This has worked for me many times. I did it a few days ago with a woman who honestly seemed like she would never ever run out of steam talking about god knows what, but sure enough, she fizzled out after about a minute. Just try it.
Thursday, May 26, 2011
Wednesday, May 25, 2011
Tales from Residency: Parameters
One day, the charge nurse dropped a chart down in front of me: "You forgot to write parameters for the Metformin."
Now usually you write parameters for blood pressure meds. Like if the patient's blood pressure is 75/30, you might not want them to get a medication that will lower their blood pressure. But Metformin is an oral medication for diabetes, which doesn't work immediately like insulin does but instead is effective over a longer period of time.
I didn't know how to react to this request. Finally I said, "I never write parameters for Metformin."
"Well, you should," she said.
I was exhausted and overwhelmed with work, as usual, and I actually tried for a second to think of a parameter I might write for Metformin. The only thing I could think of was: Hold if patient stops having diabetes. I almost said that. Instead, I just said, "Metformin doesn't cause hypoglycemia. I want the patient to get it no matter what."
Daring, huh?
Now usually you write parameters for blood pressure meds. Like if the patient's blood pressure is 75/30, you might not want them to get a medication that will lower their blood pressure. But Metformin is an oral medication for diabetes, which doesn't work immediately like insulin does but instead is effective over a longer period of time.
I didn't know how to react to this request. Finally I said, "I never write parameters for Metformin."
"Well, you should," she said.
I was exhausted and overwhelmed with work, as usual, and I actually tried for a second to think of a parameter I might write for Metformin. The only thing I could think of was: Hold if patient stops having diabetes. I almost said that. Instead, I just said, "Metformin doesn't cause hypoglycemia. I want the patient to get it no matter what."
Daring, huh?
Tuesday, May 24, 2011
Eponyms
When I was sitting around work the other day, I found a "medical crossword puzzle" lying around. All the answers were eponyms (i.e. signs named after people). These were the clues (I copied them down):
1. Referred pain to left shoulder from blood irritating diaphragm
2. Head lifts as you attempt to flatten knees
3. Inability to stand steadily with eyes closed
4. Ecchymosis over mastoid bone
5. "Cracked pot" sound when skull is percussed
6. Knees and hip flexed when head flexed
7. Pain when toes/ankle dorsiflexed
8. Carpopedal spasm when BP cuff inflates 3-4 minutes
9. Ecchymosis around umbilicus
10. Bluish discoloration of flank
11. Tapping facial nerve elicits twitching
12. Dark discoloration of oral mucosa and lips due to ingestion of grape juice
I definitely did not remember all of them and there are a few I'm not sure I ever knew. Without cheating and looking it up, how many can you get?
1. Referred pain to left shoulder from blood irritating diaphragm
2. Head lifts as you attempt to flatten knees
3. Inability to stand steadily with eyes closed
4. Ecchymosis over mastoid bone
5. "Cracked pot" sound when skull is percussed
6. Knees and hip flexed when head flexed
7. Pain when toes/ankle dorsiflexed
8. Carpopedal spasm when BP cuff inflates 3-4 minutes
9. Ecchymosis around umbilicus
10. Bluish discoloration of flank
11. Tapping facial nerve elicits twitching
12. Dark discoloration of oral mucosa and lips due to ingestion of grape juice
I definitely did not remember all of them and there are a few I'm not sure I ever knew. Without cheating and looking it up, how many can you get?
Monday, May 23, 2011
Tales From Intern Year: Step 3
When I was studying for Step 3, this was another QBank question I came across:
A 46 y.o. woman comes to the office for a health maintenance exam. Her exam is completely normal, but you notice that she has become fidgety as you turn to leave the room. You ask if there is anything bothering her and she tells you that she is concerned about her 15 year old son, who is also your patient. She says that she has walked in on her son masturbating six times in the past 2 weeks, and she found a "heterosexual adult magazine" under his mattress. She is worried about this "behavior". The most appropriate response to this patient is:
(A) From what you have told me, this seems like completely normal behavior for an adolescent boy
(B) He will regret it later on in life; masturbating causes infertility.
(C) I wish I could help but it seems that you need to take him to a psychiatrist for evaluation.
(D) It sounds like there is more to this story than you are telling me; he must have been sexually abused as a child.
(E) You should make him an appointment to see me as soon as possible; I need to evaluate him for a paraphilia.
(F) You should reprimand him next time you walk in on him masturbating.
I don't remember what the answer was, but I think I would go with:
(G) Learn to fucking KNOCK
Seriously, that poor (hypothetical) kid...
A 46 y.o. woman comes to the office for a health maintenance exam. Her exam is completely normal, but you notice that she has become fidgety as you turn to leave the room. You ask if there is anything bothering her and she tells you that she is concerned about her 15 year old son, who is also your patient. She says that she has walked in on her son masturbating six times in the past 2 weeks, and she found a "heterosexual adult magazine" under his mattress. She is worried about this "behavior". The most appropriate response to this patient is:
(A) From what you have told me, this seems like completely normal behavior for an adolescent boy
(B) He will regret it later on in life; masturbating causes infertility.
(C) I wish I could help but it seems that you need to take him to a psychiatrist for evaluation.
(D) It sounds like there is more to this story than you are telling me; he must have been sexually abused as a child.
(E) You should make him an appointment to see me as soon as possible; I need to evaluate him for a paraphilia.
(F) You should reprimand him next time you walk in on him masturbating.
I don't remember what the answer was, but I think I would go with:
(G) Learn to fucking KNOCK
Seriously, that poor (hypothetical) kid...
Saturday, May 21, 2011
Weekly Whine: No shows
I bet you think this whine is going to be about patients not showing up to appointments. But it isn't!
In rehab, there are a lot of meetings. Actually, I think in medicine, there are a lot of meetings. I know attendings who seem to spend their entire day just going to meetings.
It's not quite like that for physicians where I work. But there's a reasonable number of meetings.
What annoys me though is people who don't show up (or are extremely late) for meetings. If it's a huge meeting with like a dozen people and nobody truly cares if you're there, then whatever. But if it's a meeting with just 3-5 people and you're an integral part of the meeting, please show up. If it's a small meeting and you're the one who arranged the meeting, PLEASE show up.
I went to a recent hour-long lunch meeting that was arranged a couple of weeks in advance and all the four physicians who were supposed to be there confirmed they would show up. We also got email and text page reminders. This was the roster:
1) One physician showed up on time (me)
2) The physician who called the meeting was thirty minutes late
3) A third physician was 45 minutes late
4) A fourth physician was text-messaged when he was thirty minutes late. He replied fifteen minutes later and wrote, "That was today?" Then (obviously) didn't show up at all.
I've taken to bringing my notes to every meeting so I can get some work done while I'm inevitably sitting there waiting for everyone else to show up. I'm way too anal to show up late myself, or god forbid, not show up at all. I'm sure in ten years, I'll be blowing off meetings with everyone else.
In rehab, there are a lot of meetings. Actually, I think in medicine, there are a lot of meetings. I know attendings who seem to spend their entire day just going to meetings.
It's not quite like that for physicians where I work. But there's a reasonable number of meetings.
What annoys me though is people who don't show up (or are extremely late) for meetings. If it's a huge meeting with like a dozen people and nobody truly cares if you're there, then whatever. But if it's a meeting with just 3-5 people and you're an integral part of the meeting, please show up. If it's a small meeting and you're the one who arranged the meeting, PLEASE show up.
I went to a recent hour-long lunch meeting that was arranged a couple of weeks in advance and all the four physicians who were supposed to be there confirmed they would show up. We also got email and text page reminders. This was the roster:
1) One physician showed up on time (me)
2) The physician who called the meeting was thirty minutes late
3) A third physician was 45 minutes late
4) A fourth physician was text-messaged when he was thirty minutes late. He replied fifteen minutes later and wrote, "That was today?" Then (obviously) didn't show up at all.
I've taken to bringing my notes to every meeting so I can get some work done while I'm inevitably sitting there waiting for everyone else to show up. I'm way too anal to show up late myself, or god forbid, not show up at all. I'm sure in ten years, I'll be blowing off meetings with everyone else.
Friday, May 20, 2011
Thursday, May 19, 2011
Med School Stories: Balls
Who's got balls? Me. (Sometimes.)
During my Emergency Medicine rotation in med school, I was supposed to stay in my ER shift until 8PM. But at 6PM there wasn't a lot to do and the ER attending told me he didn't have time for me. We had to write up a few cases from the rotation, so I said, "How about if I go to the library and work on my write-up now?"
If he had been nice, he would have said, sure, go work on it and I'll see you tomorrow. But instead he told me to go work on it and then COME BACK afterwards. This attending was very suspicious of med students and would never sign my attendance sheet until the last thirty seconds of the shift, because he said when he was a med student, he used to always sneak out early. (Me: "And look how great a doctor you turned out to be!")
So naturally, instead of working on the write-up, I went out to dinner with a friend of mine for two hours. When I came back and made a show of being there, he was like, "So let's see your write-up!"
Uh oh.
So here comes that ballsy part: I said to him, "Oh, I didn't print it out." Then I added: "Would you like me to go print it now?"
Hold your breath...
"No, that's okay," he said.
What if he had said yes? I don't know what I would have done. Claimed the printer was broken? Gone to the library and started typing like crazy? Probably the latter.
During my Emergency Medicine rotation in med school, I was supposed to stay in my ER shift until 8PM. But at 6PM there wasn't a lot to do and the ER attending told me he didn't have time for me. We had to write up a few cases from the rotation, so I said, "How about if I go to the library and work on my write-up now?"
If he had been nice, he would have said, sure, go work on it and I'll see you tomorrow. But instead he told me to go work on it and then COME BACK afterwards. This attending was very suspicious of med students and would never sign my attendance sheet until the last thirty seconds of the shift, because he said when he was a med student, he used to always sneak out early. (Me: "And look how great a doctor you turned out to be!")
So naturally, instead of working on the write-up, I went out to dinner with a friend of mine for two hours. When I came back and made a show of being there, he was like, "So let's see your write-up!"
Uh oh.
So here comes that ballsy part: I said to him, "Oh, I didn't print it out." Then I added: "Would you like me to go print it now?"
Hold your breath...
"No, that's okay," he said.
What if he had said yes? I don't know what I would have done. Claimed the printer was broken? Gone to the library and started typing like crazy? Probably the latter.
Wednesday, May 18, 2011
Book Club revisited (+ a whine)
For those of you who I know are dying of curiosity to find out what happened in my book club:
Our first book was The Gargoyle. I really enjoyed it, but when I got to the meeting, only one other person actually read it. Everyone else got through maybe 50 pages (they found it boring). So you can imagine we didn't have such a great discussion. At one point, someone was analyzing the book based on the picture on the cover, and that was when I realized this was truly pointless. We ended up mostly gossiping, which was also fun.
Anyway, after that debacle, I didn't dare suggest another book.
Someone else suggested The Help, which is pretty much The Book Club Book right now. I read a page of it on Amazon and it looked reasonable. So we decided on The Help as our next book.
I'm the only one who gets the book club books from the library. I mean, books cost like $10-15 each, so why wouldn't I try to get it for free? Plus my house is cluttered enough as it is. The library is only a short drive away and I can reserve and renew books online. I got my copy of The Help faster than the person who ordered it from Amazon.
However (and this is my whine), it pisses me off that when you take out a book, you can only take it out for two weeks.
The Help is about 500 pages. When I got that giant book in my hand and realized I had two weeks to get through it, I didn't feel good about it. And because it's on hold till infinity, I wouldn't be able to renew it. Best I could do was return it late and pay the fee. Is it reasonable that we get only two weeks? How many of you can read such a long book so fast, what with our kids and our jobs and our rock and roll music? Plus I sort of enjoy not racing through a book and taking my time with it. Two weeks isn't long enough to really enjoy such a long book.
It's unfair!
Although as it turned out, I absolutely adored the book, spent all my free time reading it, and finished it in less than a week. But the principle still stands.
Also, my enjoyment of my two book club books also makes me wonder if I was too hasty in dismissing all the NYT Bestseller books as "snooty."
Our first book was The Gargoyle. I really enjoyed it, but when I got to the meeting, only one other person actually read it. Everyone else got through maybe 50 pages (they found it boring). So you can imagine we didn't have such a great discussion. At one point, someone was analyzing the book based on the picture on the cover, and that was when I realized this was truly pointless. We ended up mostly gossiping, which was also fun.
Anyway, after that debacle, I didn't dare suggest another book.
Someone else suggested The Help, which is pretty much The Book Club Book right now. I read a page of it on Amazon and it looked reasonable. So we decided on The Help as our next book.
I'm the only one who gets the book club books from the library. I mean, books cost like $10-15 each, so why wouldn't I try to get it for free? Plus my house is cluttered enough as it is. The library is only a short drive away and I can reserve and renew books online. I got my copy of The Help faster than the person who ordered it from Amazon.
However (and this is my whine), it pisses me off that when you take out a book, you can only take it out for two weeks.
The Help is about 500 pages. When I got that giant book in my hand and realized I had two weeks to get through it, I didn't feel good about it. And because it's on hold till infinity, I wouldn't be able to renew it. Best I could do was return it late and pay the fee. Is it reasonable that we get only two weeks? How many of you can read such a long book so fast, what with our kids and our jobs and our rock and roll music? Plus I sort of enjoy not racing through a book and taking my time with it. Two weeks isn't long enough to really enjoy such a long book.
It's unfair!
Although as it turned out, I absolutely adored the book, spent all my free time reading it, and finished it in less than a week. But the principle still stands.
Also, my enjoyment of my two book club books also makes me wonder if I was too hasty in dismissing all the NYT Bestseller books as "snooty."
Tuesday, May 17, 2011
How to tell your attending isn't listening
There was one inpatient rotation I did as a resident where every day there was a different attending rounding on the service with us. Considering it was rehab and most of the patients were pretty stable, I would often get the feeling that the attendings weren't listening to our presentations....
(Speaking of Journey, didn't you just know James Durbin was going to get voted off Idol when he sang Don't Stop Believing? He couldn't hope to top the Glee version and his version just sounded karaoke. Obviously he wasn't in it to win it.)
(Speaking of Journey, didn't you just know James Durbin was going to get voted off Idol when he sang Don't Stop Believing? He couldn't hope to top the Glee version and his version just sounded karaoke. Obviously he wasn't in it to win it.)
Monday, May 16, 2011
Baked goods
I love to bake and love the taste of freshly baked cookies, brownies, cake, etc. I'm a freak, I know.
Earlier in the year, I decided it would be a good way to bond with my daughter to start baking together. I bought her a tiny rolling pin, a tiny whisk, and little heart-shaped measuring cups. I realized a few things:
1) Homemade pie crust is not that hard to make and tastes beyond amazing.
2) My cookies and brownies from scratch don't taste as good as the ones from the mix.
3) I don't like nutmeg.
The baking was a bonding thing, and since I didn't want to weigh 500 pounds at the end of the year, I started bringing the results of our baking to work the next day (well, 75% of the results). I was new at my job and I'll admit that I believed bringing baked goods for the nursing staff or the team meetings might earn me some early brownie points (no pun intended). I love it when people bring in treats to work, and our unit only gets stuff maybe twice a month, if that. The food always got eaten.
However, I was recently discussing this online and someone pointed out to me that my bringing in baked goods could have actually made people resent me. What with people being on diets and my providing this unhealthy temptation, plus maybe some sense of obligation they'd feel to me to pay me back for the treats.
I'm not entirely convinced, so I'd like to take it to the peanut gallery. If someone at your work brought in baked goods for the unit/office/etc maybe once a week or every other week, how would you feel about it?
a) Love it! Baked goods are yummy!
b) I'd feel like the person was trying too hard to get people to like them
c) Resentful because of my diet
d) Neutral
e) Other
I don't know how to make surveys so you're just going to have to reply below.
Earlier in the year, I decided it would be a good way to bond with my daughter to start baking together. I bought her a tiny rolling pin, a tiny whisk, and little heart-shaped measuring cups. I realized a few things:
1) Homemade pie crust is not that hard to make and tastes beyond amazing.
2) My cookies and brownies from scratch don't taste as good as the ones from the mix.
3) I don't like nutmeg.
The baking was a bonding thing, and since I didn't want to weigh 500 pounds at the end of the year, I started bringing the results of our baking to work the next day (well, 75% of the results). I was new at my job and I'll admit that I believed bringing baked goods for the nursing staff or the team meetings might earn me some early brownie points (no pun intended). I love it when people bring in treats to work, and our unit only gets stuff maybe twice a month, if that. The food always got eaten.
However, I was recently discussing this online and someone pointed out to me that my bringing in baked goods could have actually made people resent me. What with people being on diets and my providing this unhealthy temptation, plus maybe some sense of obligation they'd feel to me to pay me back for the treats.
I'm not entirely convinced, so I'd like to take it to the peanut gallery. If someone at your work brought in baked goods for the unit/office/etc maybe once a week or every other week, how would you feel about it?
a) Love it! Baked goods are yummy!
b) I'd feel like the person was trying too hard to get people to like them
c) Resentful because of my diet
d) Neutral
e) Other
I don't know how to make surveys so you're just going to have to reply below.
Sunday, May 15, 2011
Weekly Whine: Don't you CARE?
Doctors make mistakes. That's not really a surprise. I mean, we're human. And we don't know everything, so sometimes we do the wrong thing.
But what really baffles me is how often doctors, maybe GOOD doctors, wittingly do something very questionable.
For example, I remember in residency, we once got a transfer to our rehab unit from another hospital. The patient arrived with a high fever, looking like he was about to go into septic shock. When we checked, we discovered that the physician who sent the patient to us knew about the fever and that the patient was unstable. But he still decided to transfer the patient to rehab.
I could give several more examples, some of them truly horrifying, but I don't want to violate HIPAA in any way. A lot of them involve extremely sick patients being transferred to rehab on a Friday night or right before a holiday, to a unit where there was no telemetry or even an in-house physician. I'm sure if you're in medicine, you can come up with your own examples of doctors who have knowingly acted against their patients' best interests.
I don't get it. Really. I always beat myself up for things I did wrong on call during residency, usually poor decisions made at 3AM. But these doctors were wide awake and aware that their decisions were putting their patients' lives in danger. Is it all about bottom line? Avoiding work? I have no idea.
I mean, even if you don't care about your patient, don't you care about not getting sued and maintaining your license?
But what really baffles me is how often doctors, maybe GOOD doctors, wittingly do something very questionable.
For example, I remember in residency, we once got a transfer to our rehab unit from another hospital. The patient arrived with a high fever, looking like he was about to go into septic shock. When we checked, we discovered that the physician who sent the patient to us knew about the fever and that the patient was unstable. But he still decided to transfer the patient to rehab.
I could give several more examples, some of them truly horrifying, but I don't want to violate HIPAA in any way. A lot of them involve extremely sick patients being transferred to rehab on a Friday night or right before a holiday, to a unit where there was no telemetry or even an in-house physician. I'm sure if you're in medicine, you can come up with your own examples of doctors who have knowingly acted against their patients' best interests.
I don't get it. Really. I always beat myself up for things I did wrong on call during residency, usually poor decisions made at 3AM. But these doctors were wide awake and aware that their decisions were putting their patients' lives in danger. Is it all about bottom line? Avoiding work? I have no idea.
I mean, even if you don't care about your patient, don't you care about not getting sued and maintaining your license?
Saturday, May 14, 2011
Fingernails are pretty
Last week when I was examining a patient, I scratched her. On the FACE.
I felt awful about it. It wasn't a bad scratch. And when I apologized profusely, the patient just laughed. It didn't even leave a mark, at least not one that I could see. But I definitely felt my fingernail make facial contact.
My fingernails are not the long scary kind that start curling over on themselves. I could describe them, but a picture is worth a thousand words so this is the current state of my fingernails:
I don't paint them, but I keep them clean. I can't imagine cutting them really short, just because I feel like I use fingernails as a tool of sorts. I trim them maybe one a week or every other week.
But is it appropriate to have longish fingernails as a doctor? Am I obligated to cut them shorter?
I felt awful about it. It wasn't a bad scratch. And when I apologized profusely, the patient just laughed. It didn't even leave a mark, at least not one that I could see. But I definitely felt my fingernail make facial contact.
My fingernails are not the long scary kind that start curling over on themselves. I could describe them, but a picture is worth a thousand words so this is the current state of my fingernails:
I don't paint them, but I keep them clean. I can't imagine cutting them really short, just because I feel like I use fingernails as a tool of sorts. I trim them maybe one a week or every other week.
But is it appropriate to have longish fingernails as a doctor? Am I obligated to cut them shorter?
Friday, May 13, 2011
6 Great Things about Being a Midwestern Doc
I thought I published this yesterday, but blogger went batshit crazy yesterday and now the post is gone... so... here it is again!
Pager alarms
I'm sure in the near future, communication with physicians will take place through iPhones, and that will be an eventual segue into communication via, like, microchips in the brain. But for the time being, I still have a pager.
In medical school, I had to pay for my own pager while I was at the university hospital. We had to rent it through some company, and I was SO excited to have my very own pager. I think I got five pages the whole year and most of those were joke pages from friends paging me to 911 or something.
When I was at the community hospital, they provided us with text pagers. I got a good amount of pages, although the vast majority were mass text messages telling me about a conference I was already at, or saying, "This is a test."
It wasn't until intern year that I got a genuine pager (sometimes two) that I hated with every fiber of my being.
Most pagers these days can be set to a variety of different alarm sounds. I would cycle through them, trying to find the least objectionable. There was the standard loud and annoying beep, which made me sick to my stomach. There was a muted version of this, which I couldn't always hear. There was vibration mode, which I never ever heard.
A lot of residents chose to set their pager alarms to different tunes. Some of these were recognizable songs. One resident had her alarm set to the Godfather theme and one to the theme music from Love Story. But the most baffling thing to me was that several residents set their pager alarm to sound like the Happy Birthday song.
I guess the logic is that the Happy Birthday song evokes good memories, so perhaps making your alarm sound like that will make getting pages less unpleasant. However, I think it's just the opposite. I think the unpleasantness of getting paged all the freaking time for years on end would overwhelm any happy memories from the birthday song.
I just imagine a large group of physicians who now feel physically ill every time they're at a birthday party.
I usually opted for an unrecognizable tune or the loud, annoying beep. I figured that the pages were annoying already, so may as well have the sound be annoying.
These days I allow my pager to make a more muted beeping sound. I still jump and feel ill whenever I hear my pager go off, although generally the only times I get paged are the happy occasions when a surgeon finally decides to return my call. I wonder if I'll ever lose that Pavlovian response?
In medical school, I had to pay for my own pager while I was at the university hospital. We had to rent it through some company, and I was SO excited to have my very own pager. I think I got five pages the whole year and most of those were joke pages from friends paging me to 911 or something.
When I was at the community hospital, they provided us with text pagers. I got a good amount of pages, although the vast majority were mass text messages telling me about a conference I was already at, or saying, "This is a test."
It wasn't until intern year that I got a genuine pager (sometimes two) that I hated with every fiber of my being.
Most pagers these days can be set to a variety of different alarm sounds. I would cycle through them, trying to find the least objectionable. There was the standard loud and annoying beep, which made me sick to my stomach. There was a muted version of this, which I couldn't always hear. There was vibration mode, which I never ever heard.
A lot of residents chose to set their pager alarms to different tunes. Some of these were recognizable songs. One resident had her alarm set to the Godfather theme and one to the theme music from Love Story. But the most baffling thing to me was that several residents set their pager alarm to sound like the Happy Birthday song.
I guess the logic is that the Happy Birthday song evokes good memories, so perhaps making your alarm sound like that will make getting pages less unpleasant. However, I think it's just the opposite. I think the unpleasantness of getting paged all the freaking time for years on end would overwhelm any happy memories from the birthday song.
I just imagine a large group of physicians who now feel physically ill every time they're at a birthday party.
I usually opted for an unrecognizable tune or the loud, annoying beep. I figured that the pages were annoying already, so may as well have the sound be annoying.
These days I allow my pager to make a more muted beeping sound. I still jump and feel ill whenever I hear my pager go off, although generally the only times I get paged are the happy occasions when a surgeon finally decides to return my call. I wonder if I'll ever lose that Pavlovian response?
Wednesday, May 11, 2011
Step 3 Questions
A question from QBank:
A 29 year old man comes to the office because one of his 3 sexual partners recently had a Pap smear that showed dysplasia and koilocytic changes. Her physician recommended that all her sexual partners be evaluated. He has always been healthy and has never had any sexually transmitted diseases. All of his partners are "on the pill" so they do not use condoms. Physical exam is completely unremarkable. There are no visible leasions on his anogenital region. He is still very concerned that he has an infection that you cannot see. The most appropriate next step is to
(A) advise him to return if he develops any lesions
(B) apply vinegar to his penis and scrotum
(C) recommend that he use condoms during all sexual activity
(D) Send for a fluorescent treponemal antibody absorption serology
(E) take random biopsies of the penis
(F) tell him that he is healthy
Answer: (B)
Now I know that acetic acid (which is in vinegar) can bring out lesions caused by HPV, but I've only heard of it being used in women and symptomatic males. In fact, when I looked it up on uptodate and emedicine, there was nothing mentioned about vinegar being used to diagnose men. When I finally googled "vinegar" and "HPV", they said that vinegar could be used when a guy is complaining of symptoms of warts if no lesions can be seen, however it's not that useful because it's neither sensitive nor specific. Furthermore, I've never seen a little bottle of vinegar anywhere in clinic that could be used for this purpose... maybe you have to run down to the cafeteria to get it.
So are there any guys reading this who are willing to try a little experiment? Go to your PMD, tell them that your girlfriend has dysplasia and koilocytic changes and see if they apply vinegar to your penis and scrotum. If they don't, you could tell them that they're ill-prepared for Step 3.
A 29 year old man comes to the office because one of his 3 sexual partners recently had a Pap smear that showed dysplasia and koilocytic changes. Her physician recommended that all her sexual partners be evaluated. He has always been healthy and has never had any sexually transmitted diseases. All of his partners are "on the pill" so they do not use condoms. Physical exam is completely unremarkable. There are no visible leasions on his anogenital region. He is still very concerned that he has an infection that you cannot see. The most appropriate next step is to
(A) advise him to return if he develops any lesions
(B) apply vinegar to his penis and scrotum
(C) recommend that he use condoms during all sexual activity
(D) Send for a fluorescent treponemal antibody absorption serology
(E) take random biopsies of the penis
(F) tell him that he is healthy
Answer: (B)
Now I know that acetic acid (which is in vinegar) can bring out lesions caused by HPV, but I've only heard of it being used in women and symptomatic males. In fact, when I looked it up on uptodate and emedicine, there was nothing mentioned about vinegar being used to diagnose men. When I finally googled "vinegar" and "HPV", they said that vinegar could be used when a guy is complaining of symptoms of warts if no lesions can be seen, however it's not that useful because it's neither sensitive nor specific. Furthermore, I've never seen a little bottle of vinegar anywhere in clinic that could be used for this purpose... maybe you have to run down to the cafeteria to get it.
So are there any guys reading this who are willing to try a little experiment? Go to your PMD, tell them that your girlfriend has dysplasia and koilocytic changes and see if they apply vinegar to your penis and scrotum. If they don't, you could tell them that they're ill-prepared for Step 3.
Tuesday, May 10, 2011
Tales from Residency: Preggo Brain
Preggo brain is a very real phenomenon, I can vouch for that.
When I was a resident, I was doing an H&P on a new inpatient who was somewhat demented. After I finished interviewing him, I was going over his therapy schedule for the day. He told me he was having trouble reading the schedule because he needed his glasses, but he didn't know where they were.
This happened to patients all the time. During pretty much every patient encounter, I'd end up searching for their glasses at some point. Usually they were in the bedside dresser, so I checked there first, in all the drawers. No glasses.
Then I checked the windowsill. No glasses.
I was wracking my brain to think where his glasses might be. Then the patient said, "Oh wait, I'm wearing them!"
I looked at the patient and realized that he was, indeed, wearing the glasses I had just been searching for.
"Boy, I feel dumb," he said. "I thought my glasses were lost but I was wearing them all along!"
"You feel dumb?" I retorted. "I was the one looking at you wearing your glasses."
Luckily, the patient was sufficiently confused that I don't think he was able to relate this embarrassing story to anyone else.
When I was a resident, I was doing an H&P on a new inpatient who was somewhat demented. After I finished interviewing him, I was going over his therapy schedule for the day. He told me he was having trouble reading the schedule because he needed his glasses, but he didn't know where they were.
This happened to patients all the time. During pretty much every patient encounter, I'd end up searching for their glasses at some point. Usually they were in the bedside dresser, so I checked there first, in all the drawers. No glasses.
Then I checked the windowsill. No glasses.
I was wracking my brain to think where his glasses might be. Then the patient said, "Oh wait, I'm wearing them!"
I looked at the patient and realized that he was, indeed, wearing the glasses I had just been searching for.
"Boy, I feel dumb," he said. "I thought my glasses were lost but I was wearing them all along!"
"You feel dumb?" I retorted. "I was the one looking at you wearing your glasses."
Luckily, the patient was sufficiently confused that I don't think he was able to relate this embarrassing story to anyone else.
Monday, May 9, 2011
Saturday, May 7, 2011
Weekly Whine: Intellectual Curiosity
I think I've lost my intellectual curiosity.
I think it's been gone for a while. Like, years. Maybe more than a decade.
The first time I suspected I had lost my intellectual curiosity was during my intern year. I had a patient in urgent care with diffuse aches and pains plus some abdominal discomfort and low-grade fever. Her labs were normal except for some transient eosinophilia. So we talked to ID and they came up with the idea that she might have brucellosis. Everyone was so excited about working her up for brucellosis and talking about what an interesting case it was. "Wow, can you imagine? Brucellosis!"
Aside from the fact that the woman clearly had some sort of somatization disorder and not freaking brucellosis, it occurred to me that I was totally and completely unexcited by the idea that she might have brucellosis or some other rare entity. I honestly couldn't have cared less.
But I had to fake caring. I kept commenting, "Wow, that was such an interesting case!!" I hope it wasn't too obvious that I was completely full of shit.
For a brief time in residency, I thought I regained my intellectual curiosity, but I think I might have just been kidding myself. And now... well...
I get irritated when people want to work up chronic medical conditions on my short stay inpatients. Recently I had a patient who had been suffering from a neuropathy of some sort for over thirty years. She was supposed to be on our service one week for a hip replacement. Neurology got called in and I literally was forced to spend hours making calls and tracking down old EMGs and MRIs and trying to figure out the etiology behind this chronic neuropathy. And neurology was talking about how it was so interesting and wondering what was causing it. While the truth was I couldn't care less.
We're not going to figure out the etiology of a chronic disease during a short hospital stay when our most advanced piece of technology is an X-ray machine. You want a work-up so badly? It's called an "outpatient referral."
It's kind of sad that I lost my intellectual curiosity though. It's one of those things that keeps you from being unhappy as a physician.
I think it's been gone for a while. Like, years. Maybe more than a decade.
The first time I suspected I had lost my intellectual curiosity was during my intern year. I had a patient in urgent care with diffuse aches and pains plus some abdominal discomfort and low-grade fever. Her labs were normal except for some transient eosinophilia. So we talked to ID and they came up with the idea that she might have brucellosis. Everyone was so excited about working her up for brucellosis and talking about what an interesting case it was. "Wow, can you imagine? Brucellosis!"
Aside from the fact that the woman clearly had some sort of somatization disorder and not freaking brucellosis, it occurred to me that I was totally and completely unexcited by the idea that she might have brucellosis or some other rare entity. I honestly couldn't have cared less.
But I had to fake caring. I kept commenting, "Wow, that was such an interesting case!!" I hope it wasn't too obvious that I was completely full of shit.
For a brief time in residency, I thought I regained my intellectual curiosity, but I think I might have just been kidding myself. And now... well...
I get irritated when people want to work up chronic medical conditions on my short stay inpatients. Recently I had a patient who had been suffering from a neuropathy of some sort for over thirty years. She was supposed to be on our service one week for a hip replacement. Neurology got called in and I literally was forced to spend hours making calls and tracking down old EMGs and MRIs and trying to figure out the etiology behind this chronic neuropathy. And neurology was talking about how it was so interesting and wondering what was causing it. While the truth was I couldn't care less.
We're not going to figure out the etiology of a chronic disease during a short hospital stay when our most advanced piece of technology is an X-ray machine. You want a work-up so badly? It's called an "outpatient referral."
It's kind of sad that I lost my intellectual curiosity though. It's one of those things that keeps you from being unhappy as a physician.
Friday, May 6, 2011
Manners
I might be one of the most polite doctors in the world. You might be surprised to hear that, considering I can sometimes be a bit of a bitch in my online posts and comments, but I promise that in real life, I'm pretty much ridiculously nice to everyone. To a fault, really.
For example, when someone asks me to sign an order and I do it, I then say "thank you" for some reason. If a nurse alerts me to a patient having pain or nausea or whatever, I always end the conversation by saying, "Thank you for letting me know about that." (Sometimes I wonder if it comes off as sarcastic.)
Also, whenever I write an order such as to take out a Foley catheter, I don't just write "D/C Foley," I write "Please D/C Foley." I'm fairly sure I never did that as an intern, but I guess I write fewer orders now or something, so I have time to be polite in my orders.
I guess I sort of learned to do this as a med student, when I had a resident who was really gung ho about writing "please" before his orders. He took it a step further though. After his orders, he would also write "Thank you."
Overkill, maybe?
For example, when someone asks me to sign an order and I do it, I then say "thank you" for some reason. If a nurse alerts me to a patient having pain or nausea or whatever, I always end the conversation by saying, "Thank you for letting me know about that." (Sometimes I wonder if it comes off as sarcastic.)
Also, whenever I write an order such as to take out a Foley catheter, I don't just write "D/C Foley," I write "Please D/C Foley." I'm fairly sure I never did that as an intern, but I guess I write fewer orders now or something, so I have time to be polite in my orders.
I guess I sort of learned to do this as a med student, when I had a resident who was really gung ho about writing "please" before his orders. He took it a step further though. After his orders, he would also write "Thank you."
Overkill, maybe?
Thursday, May 5, 2011
You're smart, we get it!
As a resident, I once consulted neurology about a patient who I thought was possibly having mild seizures. Neuro had a few thoughts on the seizures, but they were more gung ho about us doing something about the midline shift caused by my patient's very large craniectomy. (When the skull is gone, atmospheric pressure tends to crush the brain a bit.)
Anyway, my attending wasn't buying that replacing the skull that was removed would help our patient. So the neuro resident told us he was going to leave us an article to convince us.
So he did leave us an article.... in GERMAN.
Somehow, I was not convinced.
Anyway, my attending wasn't buying that replacing the skull that was removed would help our patient. So the neuro resident told us he was going to leave us an article to convince us.
So he did leave us an article.... in GERMAN.
Somehow, I was not convinced.
Wednesday, May 4, 2011
Making fun of patients
Doctors make fun of patients.
It's a fact and it would certainly be kind of hypocritical of me to complain about it. There are probably some doctors who don't make jokes about their patients, but those doctors are humorless automatons.
But there are different ways that it can be done. Like during our team conference, I might say, "I sneezed while I was talking to Mrs. Katz and she tried to get out of her wheelchair and make me some chicken noodle soup." And everyone will laugh and say, "Aw!" Because of course, we all love Mrs. Katz and we tell anecdotes about her like we would tell everyone about a funny thing our child said.
Humor is a coping mechanism. I think as long as you care about your patients, it's okay to sometimes make jokes, as long as the jokes aren't cruel.
There was only one time in my medical training when I was truly bothered and disturbed by patients being ridiculed. When I was a med student rotating on Labor & Delivery, the first 10-15 minutes of signout each day was devoted to making fun of patients. And I really hated it. I thought the jokes were mean and directed at women who were already going through a pretty miserable time.
For example, there was a patient who had polycystic ovarian syndrome, and as such, she suffered from hirsutism (i.e. she was hairy). She went into early labor and we were giving her magnesium to keep her baby from being delivered prematurely. The woman was nice enough and I felt bad for her. And I didn't get why the residents had to spend several minutes making fun of how hairy she was during signout each day. It's not like she had time to get her body waxed while she was going into premature labor.
By the end of the rotation, the other female med students and I adamantly agreed that we were going to make sure we were immaculately groomed before giving birth. We couldn't stand the thought of being the object of one of these ridicule sessions.
I really think it wasn't right. But naturally, none of us said anything. Truthfully, the patients were much better treated than we were.
It's a fact and it would certainly be kind of hypocritical of me to complain about it. There are probably some doctors who don't make jokes about their patients, but those doctors are humorless automatons.
But there are different ways that it can be done. Like during our team conference, I might say, "I sneezed while I was talking to Mrs. Katz and she tried to get out of her wheelchair and make me some chicken noodle soup." And everyone will laugh and say, "Aw!" Because of course, we all love Mrs. Katz and we tell anecdotes about her like we would tell everyone about a funny thing our child said.
Humor is a coping mechanism. I think as long as you care about your patients, it's okay to sometimes make jokes, as long as the jokes aren't cruel.
There was only one time in my medical training when I was truly bothered and disturbed by patients being ridiculed. When I was a med student rotating on Labor & Delivery, the first 10-15 minutes of signout each day was devoted to making fun of patients. And I really hated it. I thought the jokes were mean and directed at women who were already going through a pretty miserable time.
For example, there was a patient who had polycystic ovarian syndrome, and as such, she suffered from hirsutism (i.e. she was hairy). She went into early labor and we were giving her magnesium to keep her baby from being delivered prematurely. The woman was nice enough and I felt bad for her. And I didn't get why the residents had to spend several minutes making fun of how hairy she was during signout each day. It's not like she had time to get her body waxed while she was going into premature labor.
By the end of the rotation, the other female med students and I adamantly agreed that we were going to make sure we were immaculately groomed before giving birth. We couldn't stand the thought of being the object of one of these ridicule sessions.
I really think it wasn't right. But naturally, none of us said anything. Truthfully, the patients were much better treated than we were.
Tuesday, May 3, 2011
Baby names
For no particular reason, I've always been a little obsessed with baby names. Anyway, I was looking online at the top 20 baby girl names from the 1920s and they were the following:
Mary, Dorothy, Helen, Margaret, Ruth, Mildred, Anna, Elizabeth, Frances, Marie, Evelyn, Virginia, Alice, Florence, Rose, Lillian, Irene, Louise, Edna, Gladys
I treat a primarily geriatric population of patients and I can absolutely say this is accurate. Literally every other patient is named Dorothy. I can often guess the age of a patient (give or take five years) based on their first name. Some of these names are sort of timeless, like Anna. But others, like Mildred, are incredibly dated. Both my grandmothers' names are on that list.
Now look at the top 20 baby names of 2010:
Sophia, Isabella, Olivia, Emma, Chloe, Ava, Abigail, Madison, Ella, Addison, Emily, Lily, Mia, Avery, Grace, Hannah, Elizabeth, Charlotte, Zoe, Natalie
Notice there are only two names in common from both lists: Elizabeth and Lily/Lillian. (Although I've noticed that old Elizabeths call themselves Betty/Betsy and young Elizabeths go by Liz.)
Now as a person who lives in the year 2011, I think these names mostly sound pretty cute. (Except for Addison, which just reminds me of JFK's orange complexion.) Once again, some of those names are timeless, but I guarantee that in 70 years, Madison will probably call to mind an elderly stroke patient. (Sorry if your kid's name is Madison. Or Addison.)
You could say similar things about male names, but they tend to be much less trendy, from what I've observed. There are a lot of Joes, Johns, and Jims no matter how old the man is.
Not that I think anyone would actually take this post into consideration when choosing their kid's name, but how the name will sound fifty years from now is something to think about. After all, even 40 year old Kid Rock is regretting his name.
Mary, Dorothy, Helen, Margaret, Ruth, Mildred, Anna, Elizabeth, Frances, Marie, Evelyn, Virginia, Alice, Florence, Rose, Lillian, Irene, Louise, Edna, Gladys
I treat a primarily geriatric population of patients and I can absolutely say this is accurate. Literally every other patient is named Dorothy. I can often guess the age of a patient (give or take five years) based on their first name. Some of these names are sort of timeless, like Anna. But others, like Mildred, are incredibly dated. Both my grandmothers' names are on that list.
Now look at the top 20 baby names of 2010:
Sophia, Isabella, Olivia, Emma, Chloe, Ava, Abigail, Madison, Ella, Addison, Emily, Lily, Mia, Avery, Grace, Hannah, Elizabeth, Charlotte, Zoe, Natalie
Notice there are only two names in common from both lists: Elizabeth and Lily/Lillian. (Although I've noticed that old Elizabeths call themselves Betty/Betsy and young Elizabeths go by Liz.)
Now as a person who lives in the year 2011, I think these names mostly sound pretty cute. (Except for Addison, which just reminds me of JFK's orange complexion.) Once again, some of those names are timeless, but I guarantee that in 70 years, Madison will probably call to mind an elderly stroke patient. (Sorry if your kid's name is Madison. Or Addison.)
You could say similar things about male names, but they tend to be much less trendy, from what I've observed. There are a lot of Joes, Johns, and Jims no matter how old the man is.
Not that I think anyone would actually take this post into consideration when choosing their kid's name, but how the name will sound fifty years from now is something to think about. After all, even 40 year old Kid Rock is regretting his name.
Monday, May 2, 2011
Scrub Fashions
When I was in grade school, I used to obsessively draw pictures of different fashions. I have no idea why I did this, considering I had zero interest in my own clothes. Anyway, it turns out I'm still doing it:
Sunday, May 1, 2011
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