I hate to say this

But I'm kind of getting tired of rotations. I usually start each block off with enthusiasm, but by midway through all I want to do is hunker down to study for the shelf. Which inevitably doesn't happen as well as it should since there are the inevitable presentations, write-ups, etc to be done. And then ooops! You're in the hospital 10, 11, 12 hours a day.

Lather, rinse, repeat.

I'm also tired of waking up in the middle of the night with racing thoughts. Like, OMG! Does the MCA supply the basal ganglia too? (It does.) OMG! What are they going to ask me about on rounds tomorrow?!?!? (Only what you don't know yet.) OMG!! What if I forget to mention orientation during the mental status exam again!?!? (You'll never F THAT up again; but don't worry, you'll forget something else.)

You see, even though I seem to be able to come off as relatively competent in the beginning (you'd think that would help the anxiety, but nooooo....) I then worry: What if I fuck something up big time and really blow it. Or the team changes and you have to prove yourself all over again.

I also have to say that although the Neuro, Psych, and the Os block is *supposedly* one of the easiest, I'm still in the hospital from 7AM 'til 5, 6, 7PM. And Neuro is only three weeks long, so I get home and have to study study study. And there's NO WAY I'm going to be able to learn everything I need to for the shelf.

I just had to say it.

Which brings me to my next point. After my lovely upcoming 2 week vacation, I will be on my Medicine rotation. Which is like Neuro hours, only on steroids. I.e. 7AM - 5PM most days, EXCEPT also until 10/11/12 every 4th night including weekends. For 8 weeks. Needless to say I am not eagerly anticipating this. Even though I am (kind of) considering medicine as a specialty. You see, I like to sleep..... 8 hours or so a night. At least you get to go home "early" post call (i.e. at 12 or so). Unless you have didactics or some such that afternoon.

Woe is me.

It almost makes surgery (at my school) look like a relative cake walk. 5:30AM - 6:30PM or so? Didactics on Fridays from 7AM-2PM? No weekends?

So I guess even though I'm almost half done with the year, the real raping will begin in July. Fun stuff. NOT excited about it. And it's not really the hours, it's the stress of constantly doing something different, constantly having to re-prove yourself, constantly being hypervigilant just in case they ask you something or expect you to have already done something, even though you haven't been spoken to in hours.

Why can't this year be over, already?

Apparently all this propaganda shit works

When I asked the patient who was president, she said, "Bush."

When I asked who was running, "Clinton... and that Afghan guy."

"You mean Obama?" I asked.

"Yeah, him."

The stroke team

I think I liked being on the ward team better. This whole rounding for 5 hours(!) kind of gets to me. Admittedly, the patients are sicker, and also more interesting, but the milieu isn't quite as forgiving as the ward team was. It's more like, "What? You don't already know about ventilator settings? What? You didn't know the patient had gotten an EKG in the ED?"

Well, maybe these things are obvious to everyone else, but having not had my medicine or ED rotations yet, they are not obvious to me. Learning new things is good, but feeling like an idiot all the time is starting to get old.

On the plus side, I did get to watch a guy bleed into his head the other day as I performed a neurological exam. I know, it sounds really horrible. His family was there and everything, and I kept thinking how awful it must be to watch your relative basically stroke away in front of you and there's nothing anyone can do about it. The neuro exam was REALLY interesting though. Who knew that neglect happened in exactly the same way in real life that they describe in text books.

You see a quandary. On one hand -- Interesting! On the other hand -- Horribly tragic! And I feel guilty about finding the interesting interesting with the family standing right there watching in horror. I feel guilty about not feeling sad enough about the situation. I feel guilty about the condolences I expressed to the family which evidently came across as heart-felt, while in reality I was intrigued by what I was observing. And all this time we were powerless to do anything about it at all.

Yelling

When will people learn that yelling at their subordinates doesn't get them anywhere? Not me personally, but I've been witnessing some of my residents on my various rotations dressing down nurses, phlebotomy, the PT person, whoever, and I just don't understand why. I know they're frustrated, but still.

Because you TOTALLY catch more flies with honey than you do with vinegar.

In my experience, if asking nicely isn't going to motivate the person, being a bitch won't do it either. And they will hate you and try to fuck with you from there on out. Why is it that nobody has learned this?

I remember I used to think that if you were the boss you had to be tough. I guess to a certain extent that may be true, but toughness is conveyed by knowing what you're doing, knowing the answers to difficult questions, and being willing to admit when you need help. And NOT by acting like an asshole to your subordinates.

Is this a medicine thing, something that is inherent in the culture? Is this a product of the fact that many of these residents have never had "real" jobs before? I know they're tired, but really? They're only making things harder for themselves. Yelling is only going to bite them in the ass at a later date.

Validation and 1/2 done already!

I've liked my stint on the ward service so far. It is intense, and my patients are very very sick, but somehow I began to feel better when I discovered that the rest of my team was borderline freaked out about one of my patients as well. Maybe it was the validation that my concerns were legitimate and that I knew what I was looking at? That I'm not a total moron?

Anyway.

Tomorrow I head to the neurovascular service, i.e. the stroke team. This team takes care of the *actually* sick people who really are about to die (my patient is under THEIR care now, so I get to follow her here too). I heard someone nicknamed them the "DNR-C" team. We'll see if the stroke service lives up to their reputation.

Anyway, I hear that usually med students don't take the ICU patients since they're considered too complicated. At least until you've done your medicine rotation. So maybe I don't have to worry too much yet?

Hopefully it will be as interesting as the patients I've had on the ward service!

On one hand

It would be nice to pick up a patient who had a curable disease. Or at least one where we knew WHAT the disease was.

On the other hand, the diagnostic mysteries are much more interesting. Except when your patient starts having Cheyne-Stokes respirations. Then it's just plain scary.

I did get to do an ABG today which was exciting. 2nd try. Fortunately the patient was stuporous, so she had no idea what was going on as I poked her. Yay procedures! Yay actually doing something!

Tonight I have to prepare a presentation on opsoclonus. I.e. what can cause it. My guess is it won't be good, regardless. In general things that mess with your brainstem are bad news.

Leftover L+D Haiku

Sorry if anyone finds them in poor taste......

10 lb baby out.
Vagina intact! No tears!
Baby number 2?


No you can't abort.
Last chance is 24 weeks.
Have some more cocaine.


Bleeding will not stop.
Whisk patient to OR now.
Bye bye uterus!


40 year old mom.
Delivers baby at last.
G13P9.


Cervix dilated.
Head is finally crowning.
Push harder, woman!

Genetics in Clinical Practice

Yesterday we had yet another session on the evolving nature of the use of genetics in clinical practice. We were told that patients were very soon going to start bringing their genetic profiles to us on CD-Rom that detailed their genetic risk for specific diseases.

Isn't that interesting, boys and girls?

No.

I am imagining how I am going to tell my future patients that, isn't wonderful that they just dropped several grand on this test that likely will not alter anything about how I treat them.

See, we have this thing called family history that is usually pretty good actually. And also, when you come and tell us that you have an inversion on chromosome 15 and could that be causing your father's brain cancer? Well, 1) we really don't know, 2) at this point it's not going to change the course of therapy for your father. Even if you tell us this over and over and over again.

It's not that I oppose the use of genetics, it's just that it needs to be used intelligently. And we're still going to tell you to not become obese, don't do drugs, wear your seatbelt, and quit smoking. Even if your profile says that you're at low risk for whatever disease.

Are there exceptions -- i.e. diseases which if you know about them might alter your treatment or prognosis? Sure. But are these exceptions being described to us in genetics class? No. And plus, you need to compare the marginal benefits of the test to the marginal costs. As cool as something might sound in theory, it doesn't mean it will be of much benefit in clinical practice.

Like Sweet Maple Sugar

Today I did my first LP*! It wasn't at all what I expected, but I got the needle in on the third try which I hear isn't bad (I hit vertebra the first two tries). It wasn't hard to find the L4/L5 space either. Thank God my patient was thin!

For those who have never seen one done, in an LP, you put in a needle and let the CSF* drip out into your test tubes. Not unlike one might tap a maple tree for the sap to make maple syrup.
Question: Can you make candy out of your CSF?
Answer: Only if your patient has diabetes.

I also saw a patient with downbeat nystagmus and another one with really impressive frontal release signs. I really like my neuro floor. I guess I just am enjoying learning about the medical management of patients. I wish there was a bit more talking on this service, but there is certainly plenty of psychiatry, which is still interesting to me. I'm getting a new team tomorrow, so hopefully they will be as great as my team was this week.

Now do I like this as much as Psychiatry? Not sure. It's really different. I like that they do complete medical management, and don't seem to need to consult medicine as much for little things. I like that the physical exam is really informative and a bit of a art, unlike some of the other PE skills we have learned. The brain itself is really interesting. I wish I could remember more neuroanatomy. I also wish my patients weren't quite so sick.... but I might get used to that. It just makes me feel a little off balance when I just don't know what to do for them.

I also like the fact that the neurologists I've met have been pretty dorky. Mostly very laid back. But very very dorky. It makes me feel at home.

*LP = Lumbar Puncture
*CSF = Cerebrospinal Fluid

Happenings

So not much exciting going on in the world of Neuro today. Picked up a patient who might even turn out to be interesting, but then had to go to clinic and then missed doing his LP. Sad.

A classmate said the following to me:

Cl: Wow, you really remember a lot from Brain and Behavior.
Me: Um actually I just read about aphasias on the toilet this morning, which is why I could answer those questions. Notice I was silent when we were talking about imaging?

I guess the plus side is that I can remember what I read...

Observation #2:

On rounds we spent 20 minutes (at least that's what it felt like) listening to a patient with ALS try to talk to us. I couldn't understand anything he said being that it's hard to understand people with ALS, and because I was waaaaayyyyy at the foot of the bed, and then felt irritated that I had to stand there and pretend to be interested when he kept repeating the same things over and over and over again. Oh and then I felt guilty that I felt irritated. The person had ALS, I'm not allowed to be annoyed at him!

Well anyway.

So I was relating my irritation and feelings of guilt to a (not terribly sensitive) classmate of mine (I really should know better than to say ANYTHING to this one by now). What did I get?

Cl: God, didn't you learn anything about being tolerant of patients during psych?
Me: (In my head) Actually we learned to recognize our own irritation at patients -- i.e. our counter-transference -- and to incorporate that into our diagnosis/ treatment plan without actually acting on those feelings. Kind of like I am irritated at you now, yet am merely internally acknowledging my feelings of annoyance and not acting upon them.

EI kids. It's your friend.

And so it goes. Tomorrow I have a full day on the floor, so hopefully it will be more interesting.

Neurology

I just started Neurology today and holy mother of God is there a lot for me to learn in three weeks time. My team seems very nice and laid back though. A lot of MudPhuds, which is nice.

On that note, I'm going to now attempt to shove a bunch of neuroanatomy in my brain. Edinger Westphal Nucleus? What??

See, people DO get better

A patient we 302ed a while back stayed on the unit for my whole stint on inpatient psych. Even though her general demeanor was ornery most of the time, I was still fond of her. She'd come up to me every few days even though I wasn't part of her treatment team and say, "I'm gettin' the hell out of here today," and I'd say, "Really? That's great! Where are you going?" But alas, I'd see her again on the unit when I came in the next morning.

One day she came up to me and demanded, "Get that woman to stop botherin' me. She keeps disrespecting me!" I asked her what the other woman had done. "She asked me why I wasn't wearing clothes!" She was indignant!

I looked at the patient. She was dressed in a bright green down jacket that came down to her knees. Other items of apparel were not apparent. "Well, ARE you wearing clothes?" I asked.

"I AM WEARING CLOTHES. WHY ARE YOU ASKING ME THAT???" she was really aggravated. She started lifting up the coat to show me the polka-dot shorts she had on underneath.

"Ah, I see.... well the next time she asks you that, just say, 'I'm wearing shorts, thank you for asking' and leave it at that." "Oh," she said. She seemed pacified.

Finally one day when she told me she was leaving she said she was going to live with her aunt. "Your aunt? You told me when you came in that you had no family."

"Yeah, well I was really messed up in the head back then," she said. INSIGHT!!!! I thought. PATIENT IS SHOWING GOOD INSIGHT!!! I was really excited for her. I wanted to jump up and down. This was real progress.

She was even in a good mood and smiling yesterday. I saw her dancing in group. She seemed really up. I think they finally found a placement for her, and she was happy about that. I hope she doesn't piss the people at her new home off too much with her crankypants-ness. She's really a sweet lady at heart.

Truth

Standing outside the courthouse in North Philadelphia where we 304ed a patient this morning, I watched the patients file in and out of the methadone clinic that was right next door. And I found myself thinking:

I wonder what these people were like as children?

How did their lives get so screwed up?

Clearly they didn't go see their guidance counselors one day with the assertion: I think I want to become a hooker who abuses cocaine/heroin!

I think one of the most socially relevant things I have learned on my psych rotation is: Don't do drugs. Especially coke. Or anything else that gets you high for that matter. Because any problems you have will become magnified 1000% when you're on them. And you have no way of knowing whether you're going to be one of the unlucky ones who "can't handle it" and becomes addicted. Actually, if you think you CAN handle it, then you're probably that person we need to worry about. Tip: It's illegal for a reason.

And furthermore, that you really can't judge a person until they are fully detoxed. The most irritable obnoxious patient can turn into a relative pussycat, a sweet old man, after he'd been off the coke for a little while.

So kids, stay away from the drugs. You don't want to end up like the hookers coming out of the methadone clinic that I saw this morning, or the cirrhotic patients (from hep c and/or alcohol) who are dying of liver failure and want to kill themselves. It's just a bad scene all around.

Feeling empathy

So today, one of the patients on the psych service needed an Ob/Gyn consult. So the Ob/Gyn resident arrives. And it's one of the ones that was good to me during my rotation. I actually really liked her. But still I feel that old anxiety rising up when she asks me if I can chaperon for her while she does a speculum exam.

What do you mean by anxiety, you may be thinking? It's the what- does- she- want- me- to- do- with- myself variety. Should I position the light? Hand her the perfectly unwrapped Q-tip? Open the speculum for her so it's pristine and sterile and then smoothly hand it to her as she starts the exam? Pass her a drape for the patient? And is she going to be annoyed if I don't correctly anticipate her needs?

And all of this was complicated by the fact that I had never met the patient before. Wasn't introduced when I came in the room where she was already undressed and in the process of putting her feet in the stirrups. It's like, "Hello Ms. R's vagina. Nice to meet you too!"

And when the exam was done, the resident gave the patient the tragic news and started walking out the door. Then she came back and said, "Oh, that was really awful. Are you ok? Do you want to talk about this?" Of course the patient said no. I didn't know what to say. I barely even knew her name.

And all this time, through the delivery of the tragic news, I couldn't make myself feel empathy. I could cognitively imagine what the patient might be feeling, but I couldn't make myself feel the knot in my stomach that helps me relate better. I felt very mechanical, like I was going through the motions of expressing regret and sadness that I didn't really feel. Now I can feel something. At that time however, I just wasn't able to.

Maybe it was the anxiety of having to fill my Ob/Gyn role again. I still feel waves of frustration and anger when I run across some of the residents who were so horrible to me on that rotation at the hospital. Maybe it was that I had to focus on the tasks I had to perform so much that I didn't have the reserve I needed to feel empathy.

All I know is that I don't want to go into a specialty where that is how I must function all of the time. It really isn't pleasant and it's not the kind of doctor I want to be.

So

I spoke with the MD/PhD Administrator coordinator advisor person today since I had a few minutes in between my morning at Inpatient and my afternoon at the VA. I needed to ask her:

How many electives are we allowed to take for graduation?

I really should have asked: What is the minimum number that we HAVE to take, since her answer was that I could take as many as I wanted. But I have to take at least 4. And do one medicine or surgery sub-I. Oh, and I have to sit for my step 2s. Not PASS them, mind you. SIT.

Huh.

My Epi advisor had wanted me to figure this out because in his words, "We don't have anything for you to do in between your step 1s in February and July."

So yeah. The long and the short of it is that I can pretty much completely finish medical school before I start my PhD. With the exception of maybe 1 elective.

So NOW I understand why the MD/PhD office discourages this particular plan. You could essentially finish everything in med school, flummox around in your PhD for a few months, get nothing accomplished, and then graduate with no debt on time in 4 years. All I have to say is, they really must trust me not to do that to allow me to do the program this way.

So the current plan is the following:
Finish my core clerkships this December
Take Step 1s in February
Finish my paper that I've been putting off all this year
Take 3 electives in areas of interest and do my sub-I in March-June
Start my PhD in July

Hopefully the electives will help me narrow my focus of what I actually want to do for my PhD. And then when I return to the clinics after a 3-4 years I'll take several more electives to get back into the swing of clinical medicine, possibly do another sub-i, and then apply for residencies.

Scary. I've got my next 5-6 years mapped out.

I just had the revelation

That 10 years ago today I turned 21. The night before I had gone out to Jimmy's Woodlawn Tap right after midnight to celebrate my 21st birthday. We just hop-skip-and jumped from the Reg right over to the bar as soon as the clock struck 12.

Holy Shit.

We also went to "Study Break" on Thursday night at Figi that week, then out again Friday and Saturday.

Those were my glory days.

Who says that The University of Chicago is where fun comes to die?

Who is your favorite

Girl Next Door?

Mine is Kendra.

Honestly, there are few things more relaxing than collapsing on the couch on a Sunday afternoon with a glass of wine watching Kendra with her "pimp cup."

Which one is yours?

Holy shit I'm gonna be old when I'm done with this nonsense

As my 31st birthday rapidly approaches, for the first time ever I've started feeling old. Not NOW so much, though it's probably not an accident that I find myself more interested in talking to the MD-PhDs who are returning to the clinics after completing their PhDs than many of my now 24 year old classmates (with some exceptions, of course). And even most of them are still a few years younger than I am.

Hell, there are attendings who are younger than I am now.

I guess I've just been thinking about how when *I'm* done with my PhD, I'm going to be 36 or 37. Most of my co-interns when I start residency will be about 26-27. And despite what many of them think, there is a big difference between 27 and 37. And I start thinking -- HOLY SHIT I'M GOING TO BE OLD when I'm done with this.

Not that I didn't know this when I started this program, but I have been thinking about it a lot lately.

They tell me it's been a good week

About 3-4 classmates of mine have come up to me this week and commented on how much I seem to like psychiatry. I guess it's true to a certain extent. I like my patients, I like doing things on the wards. I like that I have actual responsibilities for once, and that I feel like I can take some initiative and not feel like I'm overstepping my bounds.

I also like that the hours don't kill me. They're not THAT cushy -- I mean, we're still in at 7:20 or so and done at 5:00, but it sure beats the 6PM - 9AM shifts I pulled on Nightfloat when I did Ob/Gyn a month ago. God. Every time I run into one of the residents from that rotation I feel waves of anxiety washing over me. Not fun, I'm telling you. Here, I actually like the people I work with, and even look forward to seeing some of them on a day to day basis.

Plus, my patients are getting better! Anti-psychotics work! The voices go away! People go home and DON'T kill themselves. We even sent a guy to hospice this week, which while depressing in a way, was also kind of cathartic in the sense that it was the best thing for him. I felt like we helped, and it felt good.

Does this mean something?

I think we'll have to see how my neurology (next) and medicine (after summer vacation) rotations go. But at least I feel like I've found something I could see myself doing.

Had a meeting with my Epi advisor this week to the tone of: So OMDG, what rotations do you like? Do you know what you're going to go into yet? Why not? What do you like? What don't you like? I'm concerned that you haven't been able to eliminate anything from your list (hello, Ob/Gyn? Are you listening to me?). What will you do after you take the boards next spring? Do you want to do genetics? How about ID? How about X? How about Y?

And you know what was frustrating? I feel like I DID tell him some definite likes that I have (cost-effectiveness analysis, psychiatry) tempered with some concerns (will I forget medicine if I do psychiatry? is it prudent to abandon all the policy work I've done in the past?), and he didn't hear me at all.

Blegh.

Anyhow. I like psychiatry. I like cost-effectiveness analysis. I think it's obvious at this point. Now the question is.... do I like anything else MORE. Wouldn't that be a good problem to have? I think so.

Sublimation*

You know how sometimes you meet someone, and it's like you click instantaneously?

Or the reverse happens, and the person just raises your hackles ever so slightly. You just get a negative we-probably-won't-be-friends vibe?

You just hope with the latter type that you're wrong. But how often does that really happen?



And then you end up working for them.



This used to happen a lot at the industrial supply company from hell. Fortunately now I am older, (a little) wiser, and can bite my tongue harder than I ever could in my youth.

I guess there isn't much else to do but be super-competent. Don't hate me because I do a good job. You know? Make them look as good to their boss as you possibly can. I wouldn't try to make friends or anything. Trying to be "friends" too early on will just make you look weak.

Occasionally I've found that if you can do that, the situation reverses itself eventually.

Has anyone else had success in situations like this?


*Sublimation: Transformation of negative emotions or instincts into positive actions, behavior, or emotion.

Head in ass

Mine, that is. I hate Mondays. I feel like every Monday, I arrive at clinic and go, "Uhhhhh.... what am I supposed to do here?" I usually figure it out, but a little too late to get everything I need to finished before rounds. And I usually forget some important detail.... and I always have some sort of excuse to myself.... like that the other medical student had the patient's chart all morning, and THAT'S why I didn't have time to review her prns* for Friday night through Saturday in addition to Sunday (which I did).

But really, what is wrong with me?

Ugh!

What can I do to remember how to do my job from Friday night to Monday morning?

I have noticed that I do well with the task completion however. I'm typically able to complete the scut for my patients before my resident remembers that I was actually supposed to be working on something. At least I can do something well.

Maybe I need to create a list for myself when I leave on Friday of the tasks that need to be done when I arrive Monday morning. Or give myself a few extra minutes in the AM when I get there.... since I have a tendency to feel a bit harried when I get in. Especially when I feel like I'm in the way.

I think I'll try that next week.

*prn = "as needed" meds

Sidebar

A few weeks ago, when I completed my Ob/Gyn rotation, I added an item to my sidebar entitled "Career Preferences du Jour." Use this, if you care to, to assess where my head is at re: what I want to do with my life. You will note that my preferences change regularly.

And while you're over there, please take the time to reacquaint yourselves with my HIPAA statement. It seems some readers have been confused of late.

PS Anon? I put up my new avatar just for you. I guess that's what eating chocolate donuts for 18 years will do to a person.

Sometimes I think it would be easier not to know

A few weeks back, Luca and I went out to brunch in the city with a couple we had met through masters swimming in Chicago. The husband was in town for the weekend for a conference at [the university affiliated with my med school], and he and his wife had decided to make a mini-vacation out of it. They had brought along their almost-2-year-old son with them.

The problem was, there was something not quite right with the boy. He had somewhat dysmorphic facial features, and the rest of his body had disproportionate features as well. It was so obvious to me, that it was difficult for me not to gasp slightly when I met him. I hoped that the parents had not noticed my reaction. I had really tried to disguise it.

Later I asked Luca if he had noticed anything about the boy. He hadn't even thought about it, he said. Had he noticed anything about my reaction? No.

Thank God.

I really hope I'm wrong, but I don't think I am. Sometimes I wish I still wasn't able to recognize these things and could remain in the dark for a little while longer, but I guess this comes with the territory when training to be a doctor.

I was just happy I was able to disguise my reaction.

I guess it's kind of like riding the trolley and noticing that they guy sitting across with you probably has acromegaly, or that a person in your class has low set ears, or that a stranger in church has a really bad looking mole. Except that when you know the person, and you know THEY don't know yet, it can be difficult.

And you don't really know what if anything to say.

Founders 11 -- Inpatient Psych

Since working on the psych ward, I see homeless people in a new light. Now, don't get me wrong here. I still usually cross to the other side of the street if I see a homeless man half clothed in a ratty t-shirt and no pants ranting and raving on the corner bearing a broken bottle. But instead of wondering abstractly what happens to these people, I now know. A little better, anyway.

And I wonder: When was the last time that patient visited Founders 11?

I mentioned this to one of the attendings (see, it's actually ok to speak to attendings in the psych department, unlike in other departments which shall not be named....) and she said, "Of course! This happens to me all the time. I feel like I must know at least 1000 homeless people who live in Philadelphia."

In fact the other day, she said, she was walking home, and a homeless woman accosted her on the street. She thought to herself, "I wonder if we'll be seeing you on my service tomorrow." And lo and behold, we did.

One of the things that has struck me, though, and makes me feel sad is that we really see these people improve on the inpatient ward. When they're taking their medications regularly and have a stable living situation (and are off the crack/booze) for a couple of days. Sure, most of them still hold onto their delusions that their food was being poisoned by the staff when they came in, or that we've been keeping their bag containing, "fine juicy steaks" away from them. But often they become a lot less agitated and labile, begin to be able to care for themselves, and sometimes even become pleasant (PLEASANT!) to talk to.

And why does this make me sad?

Because this is the point at which they get fed up with being on a locked unit, and decide to leave AMA. And they're no longer crazy enough to get a judge to commit them. So you let them go. And you know that they'll be back in a few weeks or months, probably covered in urine or feces, after having some sort of altercation with the police about someone who stole their money.

Again.

And again.

And again.

I guess it's not THAT different than sending a person with diabetes home who you know can't be compliant with their regimen, after they've been hospitalized with diabetic ketoacidosis for the 15th time. You know they won't be compliant and that you'll see them again. It's just for the schizophrenic patients, they really can't help their behavior. I guess maybe one could argue that the non-compliant patients can't help themselves either, but they're not flagrantly crazy enough to arouse my sympathies.

Sigh.

I really have been enjoying this rotation. And every so often, you see someone really get better. It's kind of amazing. Maybe later I'll tell a story about ECT.

Things People are Obsessed With

Food.

A few weeks ago on Child Psych I was interviewing a family who had a son with a serious medical problem. His mom reported that she was worried that he was depressed, and that he refused to eat his breakfast in the morning.

Later we found out from the son that the problem wasn't a lack of appetite per se, but WHAT was being served. Apparently mom had decided that only "healthy" foods were permitted, and that processed foods like white bread were forbidden because they were not as healthy as whole wheat. Sugary cereals were completely out of the question.

The thing was in this case, it was really important just to get enough calories into this kid. For his disease.

It was all I could do to keep from exclaiming, "Look lady, I ate Chocolate Donuts every morning for breakfast until I went to college and I seem to have turned out ok. Let the kid have a fucking pop tart if he wants one." But readers you would be proud of me. I bit my tongue.

It was also interesting to note that some of my classmates later revealed that they would NEVER feed their children horrible junk food like (Gasp!) SUGARY CEREAL, and the mother was completely justified in her dietary rules. The kid just had to realize that he needed to obey his mom. Hmmm...... CONTROL FREAKS!!!

Somehow, this didn't really surprise me.

:-P

Valuable Lessons

While we student doctors may not enjoy every rotation we do, I've discovered this year so far that each rotation has provided me with useful life information. Below I've compiled a list of some of the useful-to-me things I've learned:

Peds
1. Babies are boring -- all they do is shit, eat, cry, and sleep.
2. Little children between the ages of 3-8 are adorable. They talk, think, interact, and are more or less completely fascinating.
3. I'm actually good with kids.
4. I'm also good with their parents.
5. Adolescents aren't so bad if you can get them to talk to you.
6. Except the ones that are so obnoxious that you want to smack them.
7. Having a teenage child who still has to wear diapers would have to be one of the things I would most like to avoid in life.
8. Not all children are cute. Life sucks a lot more for the not-cute variety.
9. Kids don't break very easily. Pick one up! You'll see.
10. 18 month old children cry when a stranger comes near. Don't worry, it's not personal.

Ob/Gyn
1. Birth control works a lot less well than most people think.
1a. Actually, it works quite well, just not when you forget to take it. Which is what most people do.
2. Vaginal deliveries aren't nearly as revolting as I thought they would be.
3. The vagina is a very resilient organ (thank god).
4. C-sections suck. Imagine having to take care of a baby when you can barely get out of bed. Or drive. Plus, they're pretty violent. And there's a lot of blood.
5. After I have kids I'm totally getting a Mirena.
6. For the love of god, just get your damn Pap smear.
7. Uteruses can spontaneously fall out of the vaginas of older ladies. Surprisingly, this is not painful, just a bit annoying.
8. I haven't decided for sure, but I think ovarian cancer is probably one of the most unpleasant ways in which to die.
9. I will never have an intern perform a vaginal delivery on me unless I have to. Particularly not in July. This is based on something I overheard one of the Ob/Gyn interns say: "I've noticed that my patient have a lot fewer tears now than they did when I started. I guess that means I'm getting better at deliveries!".
10. If I ever give birth, I am totally getting an epidural. And to that end, I will never give birth in Italy.

Psych
1. You only have a psychiatric illness if it impairs your life/relationships in some meaningful way.
2. That said, I did not have ADHD growing up (despite what my teachers wanted to think) as I had straight As throughout childhood. And mostly As in high school and college. And because my activity level was only perceived to be a problem in one setting: i.e. Chapin -- not in multiple settings as required by the DSM-IV.
3. Lots of parents think that something is wrong with their child's behavior when in fact it is the parent who is crazy.
4. People are nuts about their food. And their digestive systems.
5. Really really shitty things can happen to perfectly healthy people to make them lose cognitive function.
6. People with mental illness often get shitty medical care. This happens for a variety of reasons.
7. It's ok to dislike your patients as long as you can separate your dislike for them and still treat them appropriately.
8. Don't abuse alcohol. It can and will fuck up your life.
9. 50% of people who abuse opiates -- i.e. use them to get high rather than to relieve pain (this includes prescription pain killers) will become dependent on them.
10. Just because you don't know why a patient feels the way he/she does doesn't mean it's not real.
11. Referring to a patient as "borderline/ narcissistic/ hysterical" because of one annoying interaction says more about the person who labels the patient than about the patient.

Antisocial Personality Disorder

I interviewed a patient the other day who had recently attempted suicide. He was professing HI* as well. I had to figure out whether he really meant it.

As I listened to him tell me about the people he had shot and beaten up and tried to kill, and how he wanted to beat the crap out of his girlfriend(s) for various offenses, and what it had been like for him in prison..... and about all the drugs he uses and alcohol he drinks..... I began to feel like maybe it was actually a shame that he hadn't succeeded in killing himself.

And then I thought: Wait, I'm supposed to feel shock and horror that I feel this way. I'm supposed to feel like, "How could I wish harm on some person! I am a healer!"

But I didn't. I didn't feel anything at all.

I just tried not to flinch when he lunged towards the phone that was right by my head.

I *was* able to do my job, and he was hospitalized later on that day because of what he'd reported to me.

And I still don't feel any moral conflict about my feelings towards him as a human being.

I've decided it's not actually a sign of dysfunction on my part. Maybe it's even a sign of being well adjusted?

Some people are scum, though. That's for sure. And he scared the shit out of me.

*Homicidal Ideation

Making a number into a verb

Like the number "302." As in: We decided to 302 Mrs. Smith yesterday.

Yesterday was my first 302. I just felt bad that we kept telling the patient that she could go as soon as the social worker had put together her paperwork for the shelter. Really we were putting together her paperwork to have her committed. I know it was for the best (she was found wandering around in traffic and was really sick also). And I know the alternative of telling her the truth would have resulted in an elopement attempt, sedation, and restraints.....

But still.

She really was so much sweeter once we gave her 5 of haldol and 2 of ativan.

Ob-Gin (+ Tonic)

I passed my Ob/Gyn shelf! At least I won't be having to revisit that one. I was reminiscing the other day about that rotation (and the 15 hour days) and how if I so desire, I will never have to see another c-section again. I really should be celebrating.

You know it's funny. Though I can remember enjoying things on that rotation -- actually I liked quite a lot of it -- it's the bad weeks that stick in my head. I wonder if it's like that for everyone.

Last week I did Child Psych. I found myself sitting there behind the 2-way mirror realizing why I was sent to the child shrink so often when I was a kid. And then realizing that according to actual diagnostic criteria, there wasn't anything wrong with me.

I think the hardest part of rotations for me is the sense that I am not productive. Last week was an exception. I felt like I did actual work and actually accomplished something when I saw my patients. I felt like I made a difference. It was really quite fulfilling. So I guess, week #2 in a row of liking this rotation? Keep your fingers crossed for week #3.

Swimmmmiiiinnnnnggggg!!!!!!!

I just got back from swimming for the first time in I don't know how many months. It was awesome. Even though I only did 1000 meters. I really want to make sure I go back regularly. Running just doesn't do it for me in the endorphin department the way that swimming does.

At which point I am deemed a rich snob

This article in the NYTimes about the sport I did when I was in high school came out today. It's about the high risk of death. It's funny that they only talk about death, and that some people deny the risk.

I should mention -- I rode horses avidly until I was 16 when I completely burned out. I did eventing from ages 13-16. At the lower levels it was really fun! As the fences got bigger and the courses harder, it became scary.

I remember quitting when I turned 16 because *I* began to become afraid of getting hurt. About once per event, a rider in my division (I only made it to the Preliminary level -- one level below the one where Daren Chiacchia in the article got into his accident) would sustain a fall that would mean a trip to the ER. Usually there was a broken arm or collarbone. Soooo.... that means (if you do the math) that 1 out of ever 20-30 or so riders at my level was going to the ER every time we went on course.

I guess the sport is more popular now? Anyway, I bring this up 1) because I have *NEVER* seen an article on eventing in a lay press newspaper before and I was excited to have a medium through which I could tell people about the sport, but not have to explain it, and 2) because I actually agree that the sport is too dangerous. See what I used to do all those long afternoons away from campus when I was in high school? I wasn't smoking pot and riding my pony into the sunset like the teachers at my high school thought I was.

Despite this, I still like Psychiatry, a lot

As I said last week, there are too many med students for too few patients on Psychiatry this block. This problem has persisted into this week, with child psychiatry. Today we had ONE new admission. And three med students. Fortunately one of the med students was off doing something else when the consult was called, but that still meant duking it out with the other one.

Ugh.

See, this may be a surprise to people who know me since everyone seems to think that being assertive is not a problem for me, but I've found that I have a LOT of trouble asserting myself to be the one who sees the patient, gives the presentation to the attending, etc. when there is another med student who just jumps in and starts telling the story. Usually this is only a problem when the other student is male. And then he talks and I never get a chance. I feel I can't interrupt for feel of being perceived as overeager or rude. And if I were to say, "Ok, let me do this one," they would look at me and think, "What is she talking about?" and get defensive or something. And then you have all this added pressure of, "Well she WANTED to do the presentation, shouldn't she have done a better job? What's HER problem?" And you draw undue negative attention to yourself.

This happened, oh pretty much every day last week. Multiple times a day. Such that I didn't give ONE SINGLE ATTENDING PRESENTATION, and only gave three others: One 1/2 presentation to the resident who walked away in the middle, one of which was in the PEEC where there were no other medical students at the time, and one other 1/2 one to the same wandering resident. And all the other medical students gave at least one if not more to the attendings during rounds, though I am certain they didn't notice that fact.

I also noticed that I was always the one to politely wait while the male medical student and the resident spoke with one another about the patient that the med student and I had just seen together. And when I tried to interject they just looked at me funny and kept talking.

Oh, and another time the attending told the resident SPECIFICALLY to give me the next new patient who came in, and then the resident turned around and gave next new patient to the male medical student who had joined us 5 minutes later (the attending was elsewhere at the time).

It really sucked, and this week I promised myself I'd be more assertive though I wasn't sure how to go about it.

Which brings me to another point. For some reason, it feels not-ok to say, "I never gave a presentation last week, and I'd really like to, so can I take this one, and you take the next one?" I know I *should* have just said it to the med student I was working with today, but didn't feel I could, and instead got really bitchy and irritated when the other medical student tried to hog the chart (for like 20 minutes -- and it was a really short chart -- 6 pages?) and when he refused to discuss the past medical history with me before we saw the patient.

All I'm saying is that it works better if everyone is out in the open about this sort of thing. None of this passive aggressive BS where both people want the work, but neither is willing to say it. I'd go into more details, but who knows who in my class reads my blog. If you want details about what actually happened, just ask.

Oh and please do. Because I know he'll be talking about me. I already heard him start.

Fortunately I finally got to do a presentation since I won at Rock-Paper-Scissors. And it was a good presentation. And DAMN IT I DESERVED IT.

Christ almighty I hope it gets easier. I'm on all of the rest of my services this year with this character and we really need to work something out.

Any tips on being assertive? Not bullshit tips that I can't actually do like, "Oh you just have to speak up!" Or, "Tell the resident/attending/course director that this is a problem."

REAL TIPS PLEASE.

Things about Psych

So, I like Psychiatry.

I like interviewing the patients, thinking about psychiatric illness, and the residents are enjoyable to be around most of the time.

I like psychopharmacology. I find it really interesting. Also the brain.

I like the fact that my longest day last week was Thursday which was 12.5 hours.... but ONLY because I was on call. And that all other days are from 8-5 or so.

I like that there is a surprisingly large amount of interaction between Psychiatry and the other services -- particularly Medicine, Ob/Gyn, and Transplant and that we talk about disease processes as they affect the entire body including the brain.

I like that I don't feel freaked out about learning all the material for this block. Not because there isn't a lot of it to know, but because it's actually interesting to me.

I even like talking to addicts, and trying to figure out which parts of their stories are lies, and which parts are truthful. I find the juxtaposition of the opinion of the addict in contrast to the addict's wife as to what is going on to be really interesting and sometimes painfully ironic.

I find end of life issues and palliative care really interesting, and I like that we're actually talking about quality of life with things like terminal ovarian cancer, and not just, Look at me cut this tumor out of this 50 year old woman's belly so we can prolong her life by a miserable 2 years. and THEN watch her die slowly and in pain. What a horrible disease.

What I don't like is that there are too many medical students and not enough patients and we compete with each other to present the MSE on the patient we just saw together.

I also don't think the over-psychoanalysis of certain syndromes is particularly useful. Like pain with no real source. Sure, her belly pain may be due to the fact that the woman can't talk about her feelings. It could also be due to the multiple abdominal surgeries she has had. Either way, you'll treat it roughly the same way.

I don't like that we spend HOURS it seems standing around doing very little. And that the service can be so disorganized. For instance, if you want us to meet you in a different place one morning, you could try TELLING US.

I don't like that Psychiatrists are mocked by the other services.

I don't like that the most useful thing I felt like I did last week was when I went to see a patient and it turned out that he was de-satting to the 70s-80s, tachypnic, and tachycardic, with chest pain, and I ran to find out if the medicine team knew this was happening to him.

I don't like that I feel useless. I like being busy even if it means my hours are a little longer.

I don't like following residents and attendings around and watching THEM interview the patients. All day. Until a new one comes in and I'm am dubbed the lucky medical student who actually gets to go interview him/her.

I don't like it when I see a patient and start thinking, well *I* would be depressed TOO if my life was like that. And then we decide that given their substance abuse history and suicidality that they would be a poor candidate for liver transplant. Which means they will die in the next year or so if not sooner. It makes me feel like the Grim Reaper. These people aren't old either.

I don't like the feeling that if I became a Psychiatrist that I would forget all of this interesting medicine I have labored so hard to learn over the past two years. I guess that happens in all specialties (ahem, Orthopedic Surgery) to a certain extent. But it seems to be REALLY prevalent in Psychiatry.


So, next week I will spend doing child psychiatry, which most people have NOT enjoyed in the past (you get to do even LESS), but I hope I'll find interesting as well. Maybe I'll get to spend some time back on the Adolescent floor. I really enjoyed that on Peds.