Poor Historian

I did a consult a while back on a patient who had cancer. She was old. She was dying. And when I was reviewing her records, it said she was a "poor historian."

When I walked into her room she was sitting up in her chair, eating her breakfast, alert, oriented, and completely conversant. She was, in fact, an excellent historian. She just spoke a little slowly, and her story was kind of complicated.

What had happened? There are a couple of possibilities:

1. Maybe last night she was really out of it when she came up to the floor. She's old, it was late, and maybe she wasn't very cooperative.

2. Maybe the resident did a crappy job.

3. Maybe the resident figured that he/she would be getting outside medical records and would be able to figure the non-emergent issues out then, rather than spending hours with this woman overnight while the pager went off over and over again.

4. Maybe it's just easier to write "poor historian" than to admit that you didn't have time to take a detailed (i.e. hour long) history. Maybe the attending would have chewed the resident out if they'd just said, "I didn't have time to get the full story last night, but I can today. Sorry." I don't find that hard to believe, actually.

My guess is that it was either 3 or 4 or both.

I can completely relate to this. Sometimes when I do a consult, I don't know what's important because I am still learning. I don't have time to go through every single study that has ever been done on the patient and read about every single admission. Part of learning to be a good doctor is learning what is important and what is not. But sometimes when you're learning, you mess that up. And then it sucks to say, "I don't know" over and over when you're presenting. It's embarrassing, and you get yelled at sometimes.

Pro: You never mess THAT up again.
Con: You might be inclined to cover up errors or bluff in the future.

And this is a problem in medicine. We are overstretched, and sometimes we can't do everything we need to. It should be ok to say you didn't have time to do something. You shouldn't have to be afraid of appearing lazy or incompetent for admitting that. A culture that doesn't allow for this seems to me like it would lead to worse care in the long run. People need slack so they can learn. So they can do a good job.

Thoughts?

Neuro

I started my Neurology elective on Monday. I'm doing the consult service as well as some 1/2 days outpatient. I have to say that it's AWESOME. I like running around and writing notes. It's fun to be the actual person who first sees the patients and gets to do the initial evaluation. I've been all over the hospital too. In the ICU, the floor, the ED.

I even like the two MS2s on the rotation.

And I've seen mostly stroke and seizure so far. And it's been fun anyway. I have to say that stroke epi is really fascinating. But I already knew that I think from last year.

The senior residents are switching next Friday, and I already know I'm getting someone I like. I hope the rest of the month continues this auspiciously.

Cross your fingers for me.

Perfection

When I was working at the consulting firm, my boss at the time, one of the best mentors I've had, gave me the following advice:

You have to be perfect all of the time. You can do a really good job, the best job of anyone around you, but if you make one small, inconsequential mistake, and that will be all anyone will remember about you.

Nowhere is this more true than in medical school. The only problem is that when you're learning something new, perfection is almost impossible to attain. Especially when you're operating within a time constraint.

When you're doing your core clerkships, not much is expected of you.* You really don't have to do much other than show up, pay attention, and answer a few silly questions correctly in order to be thought well of. If you miss something on a presentation, it's ok because people expect med students to forget things.

Now that I'm on my electives, I feel that not only am I expected to know things, but I am also given actual work to do, which I LOVE. But the only problem is that I feel like everyone expects that I do it perfectly. Or well, do things at least as well as the residents do.

This is actually impossible to do. And the result is that I feel incompetent constantly. I usually do better by the end of the rotation, but since I know that most people tend to fixate on the negative, and because their first impression is of me making a mistake, I worry that they all think I am stupid.

And then the next rotation starts and I get to feel that way all over again.

I am really tired of feeling incompetent all of the time.

I think the kicker is that I know I can't talk about this with any of my classmates because I can just imagine them nodding sympathetically. Like it never happened to them. Like they can't relate at all. And they'll say something faux-sympathetic like, "That must be difficult for you OMDG," and you know they're thinking in their heads YES!!! OMDG messed up! Awesome! I WIN!!

(Can you tell I've been feeling alienated lately?)

I really want to learn to be a good clinician. The sucky part is that I can only do this by trying and then falling on my face. I just wish it didn't mean that I have to look like an incompetent fool once a day or so.

As to whether that's really happening? I just don't have any faith that they'll be able to remember what it was like when they wore the short white coat. I have too much real world experience to believe that anyone can actually do that. And who knows, maybe I do really suck at this.




*The exception to this is during the medicine rotation on which you have your first real job ever, and are assessed on your ability to be as good as the attending.

Dear Readers

You may think you know me, but you don't. I am not equipped to to answer your burning questions about what kind of post bac you should do, or whether med school is really "as bad" as it seems on this blog. I don't know anything about you. I really can't opine.

Also, do not try to locate me on Facebook to send me your personal question that way. That is creepy and stalkerish.

Thank you,

Old MD Girl

Meh

If you want sunshine and roses (you know who you are anon troll), you should skip this post.

I ran into the classmate who did heme-onc at Pennsy after I did last night, and I asked her how she liked it. She emoted about how great it was, and how awesome the attendings were. It made me feel..... I don't know. Like there was something wrong with me.

I've had two electives in a row now that have left me with this meh feeling. I hated hated hated(!) both of them for the first two weeks, but gradually both got better over time. Enough so then I felt guilty about hating them initially, but not so much that I'm like "WOOHOO!! So totally gonna go into that!"

Next I do neurology. Neurology went well for me last year, and I don't really know why. I find it interesting intellectually, though I'm a little worried that it will be plagued with the same problems that the oncs have had: a lot of outpatient shadowing, and a painfully slow pace. And what if this year I get a resident who is NOT as big a fan of mine as the one I had last year? What if they decide I'm not so great afterall?

But mostly: What if I feel just as meh about this elective as I've felt about my last two?

See the thing is, I'm kind of expecting it. I got pretty screwed in the elective lottery. I had wanted to do anesthesia and em, and got exactly ZERO of that. And the waiting lists were 4 people deep. There was no way it was going to work out for me this spring.

I had wanted to try out something procedure-y and critical-care-y before I committed to a PhD on the subject, and now I'm going to have to do this blind. I *think* I will like it. But who really knows!

So, after getting the proverbial dick in the a** in the elective lottery, I went around trying to find electives that would be fun. I thought, "Maybe this is really an opportunity in disguise!" I got lured into heme onc by the MD PhD director who thinks that all MD-PhDs should do medicine. I picked Rad Onc because lots of PhDs do it, and it has the reputation of having great research.

Plus side: At least I don't have to worry about the fact that THE heme-onc Epi person doesn't return emails and has the reputation for being a not-so-great mentor. Or so I've heard.

And both electives were disappointing. And not fun, at least not until the last week. And to add insult to injury, I was criticized in my heme-onc eval for not being "soft" enough in my patient interactions. Since he never saw me interact with a patient during a time that I wasn't shadowing, I have no idea what he's referring to. The only thing I can think of is that at one point during the month, he made fun of the fact that I shake the hands of all of my patients. It smacked of interactions I've had in the past where I've been told by alleged friends that I'd be a bad mother, even though they've never seen me around kids.

So next I have neurology. I did actually choose to do this one, so maybe it will be different. I hope I like it, but I'm afraid it's just going to be another let down. It's just another resident I'll have to convince I'm not an idiot. Another month of stressful interactions. Another month where I don't feel like I fit and have to pretend I'm enjoying myself when I'm not. I'm so tired of that. Tired of having to have my guard up all of the time. What if I get another crappy boss who makes working for him/her painful? What if I get another eval essentially criticizing my personality?

I can't figure out what I like and don't like this way. It's never going to work. And it's too stressful.

I thought 4th year was supposed to be "The Promised Land," and it's turning out to be shadowing hell. I think I actually preferred my core clerkships. At least there you had a role, even though it was a s***ty one. And there was no pressure to pick what you were going to do for the rest of your life. Here the assumption is that you're doing these electives because you think you'll go into them. And then I hate them.

All of them.

What if I never have an elective that doesn't make me feel this way? I'm going to end up picking a specialty because I have to pick *something* and I will hate it. And this whole program will have been a colossal waste of my time.

Pearls

If you want your primary care doctor to take your symptoms seriously, avoid mentioning:

a) that you've been stressed out lately.
b) that you had a friend or family member get sick or die recently.
c) that you've been reading about X illness online.

I've seen at least 5 cancer diagnoses that had been delayed this past month from between 2 months to 2 years because the patient did something like this, and the PMD decided to blow off the abdominal pain, the weight loss, the diarrhea, etc.

Blown off. At least that's how the story gets reported to me by the patient.

Stage 1 cancer, with an 80% 5 year survival turned into stage 3 with a 40% 5 year survival. That's how they see it.

As I interview them, I think about whether I might have done the same thing had I been their PMD. Would I have chalked the 5lb weight loss to a normal fluctuation? To grief? The diarrhea to IBS? Or would I have been able to say, OBVIOUSLY. Let's get a colonoscopy/ EGD/ CT Scan. Now.

Afterall, hindsight is always 20/20, isn't it? For doctors AND for patients.

Adrenaline junky

See, I have this presentation that I have to give this Friday to mark the end of my Rad Onc rotation. It's a 20-30 minute one, so kind of long for a med student. I've known about it now for four weeks.

I was thinking about what my pre-med self would have done in such a situation. My pre-med self would have been working on this presentation the entire block. Slowly but surely. devoting extensive amounts of time to it over the weekends. Sure, I would have had to make major revisions, even start from scratch on numerous occasions, because of feedback I'd receive.

It would have been stressful. But! I would have told myself. I am reducing my stress by getting it done in advance.

Ha.

My newly found medical school self has realized how foolish I was. Realizing that multiple iterations were inevitable, giving me much lost free time that I *could* have potentially done something fun during, I have put this off until the last few days before it is due.

It's not that I didn't want to do something more before, it's just that I was unable to muster the necessary amount of stress and anxiety to sufficiently motivate myself. My threshold for stress and anxiety, it appears, has gotten a lot higher.

This is probably adaptive.

And I was right about 1 thing: I DO have to pretty much re-do everything I started on. Good thing I only wasted 4 hours of this past weekend working on it, compared to the 10 that I might have in my previous life.

Perhaps medical school has been good for something. Well, besides the obvious, anyway.

Sub-i

I got my 4th choice for sub-i. Which is to say I did not get any of the three that I wanted, and instead got 1 of the 10 that I didn't care about. But it is what it is.

Con: It's a 30 minute walk away.
Pro: Exercise! 'Cause I won't be getting much other than that during that month.

Con: No Q4 call. Part of the glamor of my med school is that on our sub-i we actually take the place of an intern rather than being an extra body as they do at most places. You get to feel what it's like to do THE REAL THING as an intern.
Pro: We have short, medium, and long call, with non-call days in between. You only stay overnight on the long call nights, and you rotate with the other intern. So really, you're Q12. Which means 4-5 fewer sleepless nights than the people at the "real" sites.

Con: It's not HUP
Pro: It's not HUP

It's a small hospital, and when I was there for Heme-Onc last month everybody was very nice. Much more so than has been my experience at HUP. I really didn't like the hyper-critical, pick pick picky unpleasant people at HUP when I did medicine, who seemed to constantly disapprove of everything. Perhaps this sub-i will be internal medicine's last gasp attempt to make me not hate it.

And well, it's only 4 weeks and then off to PhD land so who gives an F anyway.

The Good Life

On Friday, we had a visiting professor come and talk to us about prostate cancer. I suppose he is very famous. He does work at the big H.

Well anyway, after giving us what was a useful talk on GU cancers, he went around the room and asked us to tell him about ourselves. After hearing a 2-3 minute monologue from each resident or medical student, he would begin pontificating about what seemed to be important to that person and how best to maximize those values over the course of their lives.

Fine.

I mean, to me it seemed a bit arrogant. How can you possibly know enough about me from a 2 minute monologue to reflect back to me who I am and what I should do with my life?

Not as though it mattered for me really, or for the other three women present (for some reason rad onc is very man dominated), since he was mostly interested in discussing "The Good Life" with the men in the room.

And what, you may ask, is "The Good Life"? Having a career that allows you to earn enough money to feed your family, that garners you respect from your colleagues, and yet allows you to spend time with your family. Having lots of children. Having a supportive wife.

Why was it that he was unwilling to discuss "The Good Life" with the women in the room? Pretty much all he said to us is, "Yes you're very smart, now moving along." Had he gotten in trouble in the past? Did he not know what to say to us? Did he figure we heard enough about work life balance already? Did he not really care? Does he disapprove of women in his profession and think that they'd really be happier supporting men like himself in their careers?

All interesting questions. But fundamentally it made me wonder whether the definition of "The Good Life" is actually different for men than it is for women. Especially women who have careers. I also started to think about what I want for myself out of life, and where I am on that road to achieving those things.

I feel like I kind of already am living it. Even without having an established career. Even without 4 children. Even without having or being a stay at home wife.

So, readers: What do you think "The Good Life" is? Is it different for men and women? Is there only one definition?

Discuss.

Short White Coat

Yesterday at my meeting with the non-clinician, as I walked into the room, I caught him looking at my attire.

"Oh, sorry about the short white coat," I said, "I just came from clinic." It felt awkward on my all of a sudden. Nobody in the department wears their doctorly attire around the halls. Furthermore, if there IS a white coat lying around, I can assure you it's a long one.

"Well that's what med students wear," he explained. I guess to himself.

"Well, I hate it," I said.

He looked shocked. "Why?"

"I'm almost 32 years old," I said, shaking my head, unable to articulate my thoughts on the matter. He didn't get it. But. He's not a clinician, so I don't expect he would.

Oh short white coat. How do I hate you? Let me count the ways.

The short white coat is a symbol of your lowness on the totem pole. An excuse to treat you badly or to ignore anything you say. To look you up and down like the insignificant little student that you are, roll the eyes and go back to talking about your patient as though you aren't even there. You are to been seen but not heard. You are shit to everybody. Nurses, techs, admins, the people who mop the floor. Oh sure, once they get to know you they may treat you like a person. How long will that take, is the question, and will you be on a new rotation by then anyway.

The short white coat is an excuse to make a patronizing remark about your age. The worst part about it is that the people who make these remarks are often my age or younger. Nothing I did before medical school counts, apparently, though I feel like I get treated a little better once people find out that I'm older than they are. Honestly though, I shouldn't have to drop the age bomb to be treated decently.

The short white coat symbolizes your inability to get actual work done. The necessity of being at the mercy of your unavailable resident. "Can you PLEASE approve these orders? Can you PLEASE go over this patient's plan with me?"

It also symbolizes the ability of your attending to remark on your alleged professionalism (or lack thereof) ON YOUR PERMANENT RECORD, but your inability to say anything at all about the fact that she makes inappropriate remarks about her patients when standing right outside their room.

Oh, and when non-medical people see the person in the short white coat, they assume you're an arrogant little shit who thinks they know more than they do, and treat you accordingly.

Do you know how often I get the comment, "Wow, you're a medical student, but you don't actually suck!" Gee thanks guys. Thanks for assuming though!

I have five more years of that rag. FIVE. Ugh.

What to do with my life?

Today, in association with the title of this blog, I was told that I should really consider writing down my reactions to my various rotations so I could refer back to them when I was ready to make a decision about the kind of residency I wanted to do.

HAHAHAHAHAHAHA!!!!!!!!

No I didn't mention my blog. I'm not anonymous, but I don't exactly want to broadcast my opinions about my rotations (for which I receive a grade) AS I AM DOING THEM.

I guess I could go back and read some posts from last year. It might be useful. I'm kind of worried that I'll be embarrassed about what I wrote, though....


********


I also had two conversations with Epi people about what to do with my life. The first was with the head of the Epi department today about potential mentors and funding sources. It went well. I may have even tentatively decided upon a mentor, or at least a tentative area of focus. All will be revealed later. Trust me, YOU KNOW I will reveal all later. I just have to make sure he'll take me as a mentee.

And then the second conversation. Ah yes. So let's just start by saying that this second person is not a clinician, and as such CANNOT RELATE AT ALL to the plight of a medical student trying to decide what specialty to go into. I had to speak with him because he is the keeper of the pharmacoepi funds, which is the pot of money that I will tentatively be funded out of. The only problem is (obviously) I don't have a mentor yet, much less an actual topic of study.

He seemed to really want me to tell him, "Yes I am interested in studying the way in which this drug can be used to do this new thing," when really all I can say at this point is, "I kinda like this field and this field and this field, and oh this guy's not an asshole, maybe I'll do my PhD with him."

He was apparently not satisfied with this response, because then he started talking about "alternative" funding sources for "women and minorities" and I was kind of like WTF. I am not good enough for your "real" money? Good thing I have a p***y otherwise maybe I wouldn't get funded at all.

I don't think he meant anything by it, but...... that is how I took it. I just don't like the idea of getting funding (or anything else) on the basis of having a vagina.

Also, when I told him about a potential idea, he was like, "What is CVP and how does it relate to pharmacology?" As in, he really didn't know. So goes it with non-clinicians.

So anyway. Pro: Potential mentor possibly identified? Con: Induction into department full of sexists. Or a least people who don't even know what CVP* is and how it relates to pharmacology.**

I should point out that I know I should be happy to receive funding from anyone at this point, and that he's just trying to optimize the way in which his money gets allocated. Blah blah blah. It still didn't go over very well.



*Central venous pressure
**You can (attempt to) control CVP using PRESSORS which are DRUGS

******


Now I am going running. And then some wine and a movie. Because I (sort of) still can.

Self Eval

It was commented on my eval from last block that I should read more. And that my fund of knowledge was merely adequate.

My first thought was: How the heck would you know what my fund of knowledge is, anyway? You never assessed it. You never asked me anything other than the incredibly broad, "Tell me what you know about breast cancer." And then without listening to my response, you'd launch into a 15 minute monologue on the various trials that have been done on the subject as I tried really hard not to fall asleep while you were talking.

My second thought was: WHY??? I'm only going to go to PhD-land anyway to forget everything. What's the point of memorizing the staging and the various trials for every cancer you treat now? Especially since if I read about one type one night, you're only going to ask me about something I don't know the next day.

Tell me why I should worry about your opinion?

The answer is: I shouldn't. I'm here to figure out if I like what you do, to decide whether I even desire to know what you know. Not to become an expert in a month.

Ah, electives. :-)

Foley Bag

Sometimes I think to myself that I really should be a surgeon. Afterall, surgeons are totally badass, and surgery is cool. I also like the way they interact with their patients in clinic. Well, I like the way the surgeons I SAW interact with their patients, let's put it that way. They were really impressive people.

But then I run into my friend who wants to be a surgeon and am reminded of the downside: being at the hospital at 5:30 AM every day. Staying until 9PM every day. Standing doing nothing for hours until someone decides to speak to you. Lather. Rinse. Repeat.

I remember when I was on neurosurgery -- the elective on which there was no surgery less than 6 hours -- I had everything figured out. I would eat breakfast at 5AM, be at the hospital by 5:30, pee, then round. Then I would eat again at 7:15AM. A big egg sandwich with sausage and a container of water. I only allowed myself to drink three sips though. I left the rest in my white coat outside the OR to have during the day.

And then I went up to the OR. Just before my case started, I would pee. Having just given myself nourishment and emptied my bladder, I would be good to go until about 2-4 PM. No breaks.

The sad thing is, it took me A YEAR of being a 3rd year med student for me to figure out my morning routine. And I could not deviate from it lest I pass out from dehydration or hypoglycemia, or pee in my pants.

And I just can't have my life dictated by the size of my bladder. It's just not ok.

So no surgery for me. So sad. Maybe one day it will be humane, but until then, only those with elephant bladders need apply.

I wonder if any of the older surgeons have a foley bag strapped to their leg underneath their scrubs.

Hmmmmm.....

I am really glad I brought my husband with me to med school

I got a lot of unexpected comments on one of my recent posts about the difficulty people have had making friends in med school.

I was intrigued.

When I started medical school, I found myself getting sucked into a girl clique. I had never been part of a girl clique before, and it was pretty exhilarating at first. I always had someone to hang out with and watch tv with, gossip with, have lunch with. But eventually I stopped wanting to see them because they made me feel crappy about myself.

There was this underlying nastiness and competitiveness. I remember when I got my first first author paper accepted, I was so excited. We were sitting having lunch in BRB and during a lull in the conversation I decided to tell my friends.

"My paper got accepted!" I said.

Silence. You could hear the birds chirping outside. They're all staring at me.

"Congratulations." One of them said flatly.

The conversation went immediately back to how much the group leader hated her father's girlfriend. Because that was all we ever talked about. When the conversation started to drift away from that person or that topic, she would just get up and leave.

Just like in Sex in the City, we had our roles. There was the smart one, the athletic one, and the one who knew about business (how is beyond me). I was the old one. Yippee! Sometimes now I wonder whether I was in the group so that the others could congratulate themselves on how mature they were for being friends with an "old" person.

Just like in Sex in the City, our banter revolved around talking about our petty problems -- well, mostly the petty problems of the group leader to the exclusion of everything else -- combined with put downs that were intended to be funny(!) to other members of the group who did things that the other three disapproved of. Sounds like fun, right? Just like in Sex in the City!

But let's put it this way: When you see the Carrie, Charlotte, and Miranda sitting at lunch basically calling Samantha a slut to her face, it seems pretty funny. As long as you're not actually Samantha.

Eventually it got old. I started coming home and complaining about them incessantly to my husband. He urged me to stop hanging out with them. Finally, when the clerkships started, I had an excuse. And life has been 1000% better since then.

Over time I've been able to make *actual* friends with people who don't act like the petty bitches on Sex in the City. My husband is my main source of social support. I've even met some people who are at a similar stage in life as I am. Thank GOD.

I've never been a giant clique person, and I see no reason to start now.

Maybe at a later time, I'll opine on the difficulty meeting new people and making new friends when you're post college. I remember how lonely I was during my first job post college. It was really hard. Even though medical school isn't actually a "job," there are a lot of similarities. It seems the only people who don't go through this are the ones who have always had herd of people to go out partying with. But then you wonder just how close these "friendships" really are.

If you're having trouble meeting people you like or if you feel lonely, take heart. You're not alone. It gets better. You will find your place, it just may take a little time.

Rad Onc part deux

So, this week of Rad Onc was somewhat better than last. I actually got to talk to patients myself and to write actual notes. Not a lot, grant you, but more than before. It was a great improvement.

I still think the field has interesting research. What I'm coming to realize is that it's a field that places relatively few demands on your time as a clinician, so it's possible to work as a full time clinician and still put out a lot of research. And it pays really well. The downside is that since you're so lucrative for the hospital, many hospitals don't want you to spend any of your time doing research because it's not compensated as well, so you can more or less forget about the 80-20 research-clinic split.

Also, forget about it -- at least at this residency program -- if you want to do basic science research. This program places a real emphasis on clinical research. I know there are others (U Chicago) that place more emphasis on basic science, but that is not the case with this one, it seems.

So, I am still up in the air. I think my real problem with this specialty is that I don't feel like a "real" doctor. I did this week during multidisciplinary clinic, but not the rest of the time. I don't know, we'll have to see if this changes. The attendings have an enormous amount of knowledge, it's just more big picture knowledge about how cancer is cared for from a medical, surgical, and radiation perspective. They all know all the trials for why they do every single treatment in EACH of the fields, not just radiation -- probably better than either the surg oncs (who only know surgery) and the med oncs (who only know chemotherapy).* What the rad oncs lack is knowledge about how to take care of people. Well, at least in the attendings I've seen.

Ultimately I have to decide whether this will be a problem for me. Each specialty has stuff they've decided to omit for the sake of knowing the specialty area really well. I just have to decide what I'm ok with forgetting.


*I realize this is somewhat of an overgeneralization.

Med Students v. the Real World

I remember I told one of my med student classmates how I lost my job back in 2003. She gave me this patronizing look and smug smile, and made some comment about failure.

I wanted to throttle her.

If I hadn't lost my job back in 2003, I might never have come to medical school. And hell, she's in the exact same place I am. Who is she calling a failure?

The other day I asked her how her investment banker boyfriend was faring in the recession. He is still employed, apparently. He's very fortunate, I told her.

NO. She said. He's GOOD at his job.

Oh I see.

Ah, naive little medical student. How little you know about the world. I suppose in your opinion, only incompetents and morons ever lose their jobs.

Also, you are an asshole.

Food

Pro: Oncologists rarely nag their patients about being too fat or about putting on weight.

Con: Oncologists frequently nag their patients about being too skinny or about losing weight.

Pro: At least you can eat like a pig!

Con: Your throat hurts, food tastes like shit, and you feel lousy so you don't want to.

Pro: All those high fat, bad for you foods are now on the menu again.

Con: You vomit when you so much as think about them.

Pro: Your family members will stop telling you to go out and exercise.

Con: You family will turn into the Italian mother from hell. EAT EAT EAT!! Don't you love me? Are you trying to kill yourself??? Think of your family!


Really, when it comes to medicine and food, it's a no win situation.

Highlights from 2008

I thought I'd do a post on the highlights of each rotation in 2008. I've made a rule that I have to come up with at least one achievement for each rotation. Something I learned or something I'm proud of doing. Some of the blocks are a little sparse (The O's.... hello?), but others have more.

So here goes:

Inpatient Peds: Correctly diagnosing Dengue fever. Feeling "bounding" distal pulses for the first time (but thinking they were normal). Remembering that microscopic polyangitis was P-ANCA positive.

Outpatient Peds: Getting good at looking in ears. Only getting sick once. Making lots of little kids smile, and only a few cry. Learning who Lightning McQueen is.

ObGyn: Diagnosing a stage 3 decub that we'd given the patient that nobody else had noticed. Successfully cutting the cord and not having it spray the room like a garden hose. Catching a baby. Not crying in front of my uber-bitch resident. Getting the woman at the VA to open up and talk to me when the attending told me that she "never talked to anyone."

Psych: Diagnosing a patient with a UTI and dehydration, when the psych team just thought it was just her ECT making her demented. Being the person another patient chose to tell that she'd tried to kill herself. Learning about countertransferance and how to use it when working up a patient. Realizing that it's ok to dislike your patients, and to learn to separate this from your diagnosis, treatment plan, and behavior towards them.

Neuro: Realizing that a patient was having Cheyne Stokes breathing. Doing an LP on my first try! Getting a little better at taking histories. Learning where to gather data from and what was important so that I could work patients up with no help from my resident. Being independent.

Ophtho: Seeing the fundus well enough to tell that the blood vessels were severely messed up and that the optic disc had blurry margins.

Ortho: Remembering what WOMAC stands for. Remembering what Fanconi anemia was.

ENT: Remembering 2 things about thyroid cancer.

Medicine: Realizing that my patient's chief complaint was abdominal pain and NOT palpitations (even though my team bottomed out her pressure after I went home and got her sent to the ICU before I could present her the next day). Successfully managing all of my intern's patients. Managing hypertensive urgency with no help from my intern or resident. Feeling more confident during my presentations. Using the literature to make a treatment decision about a patient's anti-hypertensive meds in the setting or renal transplant. Diagnosing possible pyoderma gangrenosum. Doing compressions during a code. Learning why people hate treating psych patients on the medicine service.

Family Medicine: Correctly working up a neuropathy. Correctly diagnosing a patient with Sjogren's rather than Lupus. Getting really good at taking blood pressures.

Urology: First assisting on something. Tying surgical knots.... twice. Not hitting a 4th year sub-i rotating from another med school when he made particularly douchey and condescending remarks towards me.

Neurosurgery: Burr holes. Cutting brain. Sewing scalp. Learning to sew prettily. Setting up patients and taking initiative in the OR. Asking over and over whether I could do stuff and occasionally being allowed to. Allowing myself not to care what people thought of me and to enjoy myself. Making nice with scrub nurses (except 1).

EM: Appropriately realizing that a patient had sepsis and fetching my resident. Getting good the pelvic exam and speculum exam. Doing IVs. Learning how to put someone on the monitor. Putting someone on fluids. Taking fast but thorough histories. Being more succinct. Being ok with the idea that I may not get EVERYTHING during the history, and that this is ok. Realizing that when the attending asks you things you've already told them, it's not because they think you screwed up. Realizing that the ER brings out the worst in patients.

Anesthesiology: Tubing a patient. First try.

Trauma: Getting good at the primary survey. Hearing a pneumothorax (via decreased breath sounds), having the fellow rip the stethoscope from my hands, declare me wrong, and then be proven correct on chest CT (ok this was probably luck, but it was still AWESOME). Closing a case (staples) by MYSELF in the OR without supervision over night. Getting good at suturing. Feeling at home in the hospital.... finally. Tubing a patient.... again (I used to ask anesthesia if I could do stuff since the surgeons would never let me).

Maybe I'll write about my horror stories someday. Nah. Why dwell. Besides, these are cynical enough.

Food

Can someone please explain to me why women check out (and subsequently gossip about) what all the other girls are eating? I feel lucky to be mostly oblivious to this phenomenon, but occasionally this culture bangs me over the head like a fried drumstick. I really just don't get how one can be more fixated on looking at what the other girls at the table are eating than on what is going into your OWN mouth.

I guess I first noticed this in high school while dining at the table shared by the rice cake girls, but it has come back up in med school. Some ladies I used to associate with used to speak with faux concern about how little such and such skinny classmate ate, and how they were SO CONCERNED about her weight loss.

I was not fooled. There was no actual concern for this young woman's alleged anorexia. The undercurrent felt strongly like.... jealousy? As in, I wish I were skinny like that bi-atch, but she has an UNHEALTHY lifestyle, so even if I am fatter (and thus uglier) at least I know I am better than she is. If I were UNHEALTHY like she is, I too could be hot.

Annoying. Focus on your own problems, ladies. We all have our crosses to bear.

House

Luca and I just came back from looking at houses. We saw a great one that was this huge 100 year old monstrosity on the edge of the ghetto. It had three floors. Plus an attic. Plus a basement. Both of which you could stand in.

And in the basement there was a bouldering wall.

At first our agent thought it was a structural support thing, but you could see the pieces of tape on it where there had been holds screwed in. The owner also had one of those peg boards that rock climbers use for strength training.

Ah, harkening back to the days when I used to climb. TEN FREAKING YEARS AGO!!

It made me feel like the people who lived there were "normal." Like my husband and I. I.e. not obsessed with the stainless steel appliances and the granite counter tops. Interested in utility. In hobbies. In a good life.

It's way overpriced for the amount of work it needs, but it was still fun to look at.

And who knows? Maybe they'll reduce it by 80K.

The thing about cancer

Is that really, it doesn't actually change much. You've always had an expiration date. Before the marvels of modern medicine, there wasn't much people could do about these things. Your time was up when it was up. If you got cancer, the mass would grow and spread, and you would die. You just didn't know in advance when that date was.

What's scary about a cancer diagnosis now is that it highlights in big bold letters that your date MAY be coming up. If the cancer is small, or incidentally discovered, you may feel completely fine, but the date is still there. You learn that if you were to do nothing, you'd likely feel well for a while still, and then decline and die quickly at some point in the future. And then the cancer doctor tells you about all the things we're going to do to push that date as far back as possible.

The doctor may say things like "cure" which basically means erasing the premature expiration date and replacing it with another one that you will learn about later. But just like a piece of paper with some pencil marks on it, you can't really ever erase the date. It will always be there reminding you that you were this close to being done.

If you're incurable, the doctor will use words like "palliate," which basically means making your death as comfortable as possible for you and your loved ones.

With some cancers, you can get treated and have a "remission" which will likely relapse at some point in time. The doctor is pushing back the date, but not erasing it completely. With the drugs we have these days, this is possible for a lot of types of cancer. It's like living with a chronic disease, except you get to spend the rest of your life looking at that big date written in red on the wall. How long will this remission last? If I relapse, will there be something else I can try to go for another remission? You become a forever-patient.

When it's time to die, there comes a point when you and your doctor get to make some decisions. Would you rather die of a brain met, completely oblivious to everything that's going on around you, unable to care for yourself or even talk perhaps? Or would you rather die in horrible pain of something that happens to your body, but completely cognizant and able to interact meaningfully with your loved ones? Pick your poison.

The thing about medicine is that we're done such a good job of fixing things like the heart and lungs, that relatively few people get to die a sudden painless death in their sleep of an arrhythmia anymore. They say that eventually we'll have fixed all the other diseases and that everyone will end up dying of cancer. And we'll get better at diagnosing things early, that more and more people will know their magic date earlier and earlier. We'll get to live longer, but as a patient for a greater percentage of our lives.

Not sure that's desirable. But then you see a 40 year old with cancer and two small children and you say THANK GOD we've come as far as we have. Thank god.