My last week at the clinic was brutal. It's amazing that I'm saying that considering that it is "clinic", which is outpatient, which is "easy"...but it was rough. I'm not coming down on clinic work, I actually enjoy it and I look forward to working in a clinic again...just not that one. Please understand that I am speaking very objectively without prejudice when I say that working with a Spanish population when you don't speak Spanish is a complete pain in the @$$. I would see maybe one English speaker a day, which was always a treat because of how fast I could fly through the interview, diagnosis, and treatment process. But those intermittent "treats" were not enough to "lighten the load" of patients who took twice the time to speak to. To make that last semana (I've gotten much better at my Spanish by the way) extra special I also got sick.
This is my first time getting sick as a doctor. While it sounds stupid to say it that way, getting sick in previous "roles" has always afforded me the option of actually taking sick leave when you don't feel like going to work. As a student in grade school and high school, you always had to convince your parents to let you stay home. In college you wore the pants and going to school wasn't "mandatory" anymore. In medical school we were similar to residents in the type of work we did, however the responsibility of taking care of patients, in the end, always rested solely on the residents shoulders, which is what I am now. Suddenly I find myself in this new world without sick days.
Yes we still have sick days, but we might as well not. On inpatient, if I am sick, who is going to take care of my complex patients? Sure, the other residents are top notch and could manage, but deep down you still have this feeling that your patient's care would suffer if a new person were to be suddenly thrown without warning into all their health complexities. On outpatient, where I am now, there is no obligation to the patient. Most aren't actually "sick" and shouldn't even be there. Also even if I were to be gone, another resident just as good as me or better would see that patient that should have been mine. What has changed is that suddenly my absence ends up hanging my friends with all of my work. Suddenly, although I feel like crap, although I feel like laying in bed and dieing, there is this stabbing pang of responsibility and obligation. To my horror, I find myself slowly getting out of bed and placing one foot in front of the other towards that damn white coat ;P.
It's a trivial thing to write about, the change in your sick days from a student to a doctor...but it's not such a trivial thing when you are used to having that freedom and now you find that particular nicety barred from you by new found responsibility. Beware students...beware. ;P
Newbie Doc
Saturday, October 30, 2010
Monday, October 25, 2010
Under the Magnifying Glass
I remember my first week of college. I remember sitting at a stop light with my new room mate, Kyle. As we sat there a green light turned in the perpendicular street and cars slowly started to march across our path, as they made an arching left turn, driving down the opposite way we had came. He asked me if I ever "just watched the faces in the cars as they passed by" wondering who they were, what they were doing...what they were going to do. That memory sticks in my head, a person I considered a relative stranger making such a randomly honest statement to me, it caught me off guard, I lied stating I hadn't ever put much thought into it. When he had said that, I thought he was weird...and I thought was weird for secretly doing the same thing, but I was young, and as time went on I realized it's one of those taboo things we, people in general, don't exactly "talk" about, after all, it's not always so "benign" to quickly place a person under your magnifying glass.
A very naive 6 year old says, "Are you pregnant?" to a store clerk as his mother checks out at walmart...the mother blushes and begins to check out faster...the store clerk is not pregnant.
A white supremacist screams racial slurs as an African American carries her back pack into a desegregated school for the first time.
The truth is making quick decisions and judgments off of very little is what we all do, it's a survival instinct that is as burned into us as much as the instinct of a bird flying south for the winter. The truth is most of the time it is very useful helping us navigate this social world we are all apart of, but in the rare instances when it doesn't work, you end up as the example of the word "moron" in some doctor's blog ;P
In training to be a doctor, that magnifying glass isn't "gifted" to you, it simply adds a couple more powers of vision for you to see through. Before school you see a sickly man pushing a cart down the isle of a supermarket. You look at the man, you see his disheveled appearance, you look at the large amount of booze he has in his cart and you know what's got him that way. After medical school you look at a similar sickly man, you realize he is jaundiced, you think he probably has liver failure, you glance at his shopping cart expecting booze...but it has toilet paper and cereal in it, (laughably) you STILL immediately think, "alcoholic".
However, as I'm going through residency I'm discovering how it's tempering my judgments. How in meeting patient after patient and getting to know the most intimate details about them, that nothing is as simple as the magnifying glass makes it seem. The alcoholic sometimes has a VERY good reason for being that way, even if his lifestyle is an unsavory one. You start to see that the mother who hit the child isn't always a monster, sometimes she's just a very stressed out woman in a bad situation, that was pushed and pushed 'till she snapped. More and more, I'm coming to the realization that this "magnifying glass" was never meant to be used all by itself, that's why when our teachers were sharpening our vision in medical school they were also teaching us to talk to our patients...to empathize with them...otherwise we run the risk of focusing that glass too much in one place and that can be a very dangerous thing.
Newbie Doc
A very naive 6 year old says, "Are you pregnant?" to a store clerk as his mother checks out at walmart...the mother blushes and begins to check out faster...the store clerk is not pregnant.
A white supremacist screams racial slurs as an African American carries her back pack into a desegregated school for the first time.
The truth is making quick decisions and judgments off of very little is what we all do, it's a survival instinct that is as burned into us as much as the instinct of a bird flying south for the winter. The truth is most of the time it is very useful helping us navigate this social world we are all apart of, but in the rare instances when it doesn't work, you end up as the example of the word "moron" in some doctor's blog ;P
In training to be a doctor, that magnifying glass isn't "gifted" to you, it simply adds a couple more powers of vision for you to see through. Before school you see a sickly man pushing a cart down the isle of a supermarket. You look at the man, you see his disheveled appearance, you look at the large amount of booze he has in his cart and you know what's got him that way. After medical school you look at a similar sickly man, you realize he is jaundiced, you think he probably has liver failure, you glance at his shopping cart expecting booze...but it has toilet paper and cereal in it, (laughably) you STILL immediately think, "alcoholic".
However, as I'm going through residency I'm discovering how it's tempering my judgments. How in meeting patient after patient and getting to know the most intimate details about them, that nothing is as simple as the magnifying glass makes it seem. The alcoholic sometimes has a VERY good reason for being that way, even if his lifestyle is an unsavory one. You start to see that the mother who hit the child isn't always a monster, sometimes she's just a very stressed out woman in a bad situation, that was pushed and pushed 'till she snapped. More and more, I'm coming to the realization that this "magnifying glass" was never meant to be used all by itself, that's why when our teachers were sharpening our vision in medical school they were also teaching us to talk to our patients...to empathize with them...otherwise we run the risk of focusing that glass too much in one place and that can be a very dangerous thing.
Newbie Doc
Clouds
One of the things that has really helped me through medical school and now residency is my childhood on the farm. It was a place of uncharacteristic freedom as well as unending responsibility. From an early age my brothers and I were expected to get up before the sun did and do the chores, though I'm sure by my father's and my grandfather's standards we would be considered highly spoiled, yet our "spoiled" is a far cry from what I see roll into my clinic these days. I remember times when Jason (my brother) and I would return home from school. As we sat around the house, watching TV, playing video games, and (in Jason's case) playing basketball, the radio would sound off and it would be our father. He would be needing our help with something, although now I'm sure the task would seem trivial, to two young boys wanting nothing more than to play it was something to be feared and hated. Upon hearing the radio, "Jake. Jason. Ya got a copy." We would often share a quick moment of recognition, our eyes would narrow, thinking the same thing, we would both bolt for the bathroom...you see if you could lock yourself in the bathroom, you could say that you were busy, if you were busy, the other would have to answer the radio, and if only one of us was needed for work (which would be the one that answered the radio), the other would get to stay home, free from work and worry.
Recounting that story, it always seems to make me smile. As the years went by and our responsibility increased that knee-jerk reflex to work was slowly trained out of us and somewhere in there we gained our father's ability to simply get the job done. It seems like such a simple thing to say it - if a job needs done, better get to it. Yet, everyday I see a large number of my co-workers which can't manage a task without an inordinate amount of complaining and foul attitude. In that respect, a few are still much like 7 year olds, hiding from the call of responsibility.
In medicine, there are residents that get marked as "dark clouds". These are the residents that seem to always get the complicated patients, they are forever stuck with more patients than others, and should it come to a competition in "horror stories" they have the market cornered. There are also those residents which are known as "white clouds", for which only good things happen. It seems that these "white clouds" are constantly getting patients that turn the corner, they join services that seem blessed by God himself, and even when things turn a bit "stormy", somehow things seem to work out. I can't speak for other white clouds, but in my experience I'm less of a white cloud for the work I get and more so because I don't complain. I've had horrible nights and dark days during this residency, some of which I have shared on here, but even when it's rough, I make an effort to contain it, to keep it from spreading to the people I work with. Not to say that I haven't learned that there is a place and time to ask for help...because there definitely is...but life on the farm with my father taught me that there is a grind to life and it is made worse if one of the cogs in the machine is a squeaky one.
For the longest time I really did believe in these "clouds". It really did seem like my dark counterparts were amazingly unlucky. One rough night on call I was working with a fellow "lucky" senior resident, Sam. We went into call with a low load of patients and went on to gain the maximum amount of patients we could admit that night, we capped out. It was a long and sleepless night and at the end of it we sat with 20 minutes of spare time before the morning residents arrived and checkout would begin.
- at 6am all of the day residents arrive and you hand over their patients to them, telling them if any issues or problems occurred overnight..you then go back to work taking care of your patients until 12pm, when you get to checkout and leave -
I don't remember the whole conversation specifically just a quick exchange that left me thinking. Sam was saying how he and another senior residents were really annoyed with a particular co-worker who never seemed to stop complaining. I reminded him that in her defense, she was a dark cloud. To which he replied, "I can never tell if they are dark clouds because they are unlucky or they are dark clouds because they complain so much." And I realized that I couldn't either.
It's not my intention to come down on those of the "stormy" disposition, but lucky or unlucky, you still have a choice in how you present yourself to the world and in my experience it can have a very positive or negative effect on not only yourself, but also those around you.
Newbie Doc
Recounting that story, it always seems to make me smile. As the years went by and our responsibility increased that knee-jerk reflex to work was slowly trained out of us and somewhere in there we gained our father's ability to simply get the job done. It seems like such a simple thing to say it - if a job needs done, better get to it. Yet, everyday I see a large number of my co-workers which can't manage a task without an inordinate amount of complaining and foul attitude. In that respect, a few are still much like 7 year olds, hiding from the call of responsibility.
In medicine, there are residents that get marked as "dark clouds". These are the residents that seem to always get the complicated patients, they are forever stuck with more patients than others, and should it come to a competition in "horror stories" they have the market cornered. There are also those residents which are known as "white clouds", for which only good things happen. It seems that these "white clouds" are constantly getting patients that turn the corner, they join services that seem blessed by God himself, and even when things turn a bit "stormy", somehow things seem to work out. I can't speak for other white clouds, but in my experience I'm less of a white cloud for the work I get and more so because I don't complain. I've had horrible nights and dark days during this residency, some of which I have shared on here, but even when it's rough, I make an effort to contain it, to keep it from spreading to the people I work with. Not to say that I haven't learned that there is a place and time to ask for help...because there definitely is...but life on the farm with my father taught me that there is a grind to life and it is made worse if one of the cogs in the machine is a squeaky one.
For the longest time I really did believe in these "clouds". It really did seem like my dark counterparts were amazingly unlucky. One rough night on call I was working with a fellow "lucky" senior resident, Sam. We went into call with a low load of patients and went on to gain the maximum amount of patients we could admit that night, we capped out. It was a long and sleepless night and at the end of it we sat with 20 minutes of spare time before the morning residents arrived and checkout would begin.
- at 6am all of the day residents arrive and you hand over their patients to them, telling them if any issues or problems occurred overnight..you then go back to work taking care of your patients until 12pm, when you get to checkout and leave -
I don't remember the whole conversation specifically just a quick exchange that left me thinking. Sam was saying how he and another senior residents were really annoyed with a particular co-worker who never seemed to stop complaining. I reminded him that in her defense, she was a dark cloud. To which he replied, "I can never tell if they are dark clouds because they are unlucky or they are dark clouds because they complain so much." And I realized that I couldn't either.
It's not my intention to come down on those of the "stormy" disposition, but lucky or unlucky, you still have a choice in how you present yourself to the world and in my experience it can have a very positive or negative effect on not only yourself, but also those around you.
Newbie Doc
Thursday, October 21, 2010
Wednesday, October 20, 2010
Getting Bucked Off
What an amazingly beautiful day. I woke up with a quiet sprinkling of rain drops on our bedroom window, when I walked out the door I was greeted with a vanilla sky with a shining sun, rays bursting through the clouds. That's how the whole day went, the patients came in on time, things moved silky smooth. My fellow residents joked around in between patients and things just seemed uncharacteristically optimistic. I had a patient come in with text book illness, which shows just how odd the day was...there is no such thing as text book illness. We read about diseases, but they don't read about themselves, it's a very rare day when you get a patient that presents exactly like a test question.
A 6 year old male previously healthy presents with a 6 month history of behavioral changes and pica (eating odd things). He lives in a house built before the 1970's that has lots of pealing paint. He likes to play outside in the dirt, unsupervised.
Uhh...is the answer B. High Risk for Lead Poisoning?
So rare does it happen that I really didn't expect the lead level to come back abnormal...but it did. That's how the whole day was...uncharacteristically perfect...but then I checked my email...I hate email. We had to take an "in-service" exam the day we entered residency. It's a test that checks to see if your knowledge base is adequate enough that you will likely pass your pediatrics boards at the end of a 3 year residency program...there is a 30% chance that I will fail. Damn...
I'm not exactly worried about it. I've never had a problem passing tests, but from time to time I get caught with my pants down...the day I took this test was one of those days. I just wanted to squash the rumors that I'm perfect ;P in case any were floating around...this isn't the first test that I have failed to pass. I often do very well on exams, but this would be my 5th "bad" test in my 9 years of upper level schooling. I remember every one I've done poorly on and there isn't a one that I look back on and say "Gee that was a great life lesson!" Nope every one of them depresses the hell out of me, regardless of all the rationalization I throw into my fire of disappointment, it never seems to quash the flames. I know I'll pass boards. I've never failed a standardized test and my board scores (the tests you take at the end of medical school) predict that I have a >90% chance of passing the pediatric license exam at the end of residency, but I still feel like an idiot. They aught to have a class on failing before you start college, because knowing how to get back on the horse is almost as important as learning how not to get bucked off in the first place. I don't know if this is great advice to those in similar situations but here's what I do.
1. I try not to freak out about my bad performance. I do something that relaxes me for a bit.
2. I then tear apart the events leading up to the failure until I have a good understanding of what caused the it (ideally that's #2 but I've usually been doing it for awhile before I find time for #1).
3. I work on any weaknesses that I spot from #2.
4. I try like hell not to make the same mistake twice.
I've always thought that if you follow those steps...especially #4 that you can close your eyes at night with a clear conscience...that's the only thing that puts me at peace when something like that happens...that and a couple beers when I get home. Alright...it's time to study : )
Newbie Doc
A 6 year old male previously healthy presents with a 6 month history of behavioral changes and pica (eating odd things). He lives in a house built before the 1970's that has lots of pealing paint. He likes to play outside in the dirt, unsupervised.
Uhh...is the answer B. High Risk for Lead Poisoning?
So rare does it happen that I really didn't expect the lead level to come back abnormal...but it did. That's how the whole day was...uncharacteristically perfect...but then I checked my email...I hate email. We had to take an "in-service" exam the day we entered residency. It's a test that checks to see if your knowledge base is adequate enough that you will likely pass your pediatrics boards at the end of a 3 year residency program...there is a 30% chance that I will fail. Damn...
I'm not exactly worried about it. I've never had a problem passing tests, but from time to time I get caught with my pants down...the day I took this test was one of those days. I just wanted to squash the rumors that I'm perfect ;P in case any were floating around...this isn't the first test that I have failed to pass. I often do very well on exams, but this would be my 5th "bad" test in my 9 years of upper level schooling. I remember every one I've done poorly on and there isn't a one that I look back on and say "Gee that was a great life lesson!" Nope every one of them depresses the hell out of me, regardless of all the rationalization I throw into my fire of disappointment, it never seems to quash the flames. I know I'll pass boards. I've never failed a standardized test and my board scores (the tests you take at the end of medical school) predict that I have a >90% chance of passing the pediatric license exam at the end of residency, but I still feel like an idiot. They aught to have a class on failing before you start college, because knowing how to get back on the horse is almost as important as learning how not to get bucked off in the first place. I don't know if this is great advice to those in similar situations but here's what I do.
1. I try not to freak out about my bad performance. I do something that relaxes me for a bit.
2. I then tear apart the events leading up to the failure until I have a good understanding of what caused the it (ideally that's #2 but I've usually been doing it for awhile before I find time for #1).
3. I work on any weaknesses that I spot from #2.
4. I try like hell not to make the same mistake twice.
I've always thought that if you follow those steps...especially #4 that you can close your eyes at night with a clear conscience...that's the only thing that puts me at peace when something like that happens...that and a couple beers when I get home. Alright...it's time to study : )
Newbie Doc
Tuesday, October 19, 2010
Stay Tuned For "As The Colonoscope Turns"
I got an email from a friend about my last post on well child checks and I realized I may have not given them the good "shake" they deserve. The truth is that while well child checks are extremely boring...so are vaccines...you never get to run down the hall shouting "QUICK THIS CHILD NEEDS 50 CC'S OF THE FLU VACCINE STAT!!!" That's because if your kid already has the flu, the vaccine isn't going to help diddly. It's preventative medicine...it is in a way pretty boring, but if I asked you what the single greatest medical miracle of the 20th century was...it's not the heart transplant, the gene transfer, or even the invention of antibiotics...it's mass distribution of vaccines to the public...boring, quiet, unassuming vaccines. It's also well child checks that catch childhood heart defects before the little guy drops dead on the base ball field. It's prevention-medicine that stops mom from giving her baby girl 8 sippy-cups of apple juice a day...if you help a child live a healthy childhood you can do all sorts of amazing things that McDreamy could only Mcdream of...you can, in effect, "cure" diabetes, cut out heart disease, and even in some instances prevent cancer. The truth is that although preventative medicine is the single strongest "pill" we have against disease, there will likely never be a TV show drama "Vaccine Central" or "Preventative Medicine: Miami" (as catchy as those names may be). Preventative medicine saves life and even gives it in a way, I hope this young, immature doc didn't put to much of a bad spin on it in his last post, and if he did, hopefully this will set things straighter.
Newbie Doc
Newbie Doc
Monday, October 18, 2010
Two Towers
I had a girl with "chest pain" as the chief complaint as my last patient before exiting the ED tonight. It really made me think how far I had come and how much more experience I've had in the few months that I've been a "doctor". As I walked into see this patient, I walked in with an interpreter and a student, confidently I took control of the situation, slowly dissecting the history to reveal what was causing her problem. Quickly ruling out the serious causes and pairing it down to only a few unconcerning possibilities. As my diagnosis became more clear the plan seemed to logically follow from it to get an electrocardiogram and a chest x-ray to rule out the unlikely but serious problems and have her follow up with her pediatrician for what likely were panic attacks. Not to say that I've suddenly become this genius in the past few months, but I've become much more confident in my logic and my decisions. That patient 3 months ago would have freaked me out. I would have stuttered my way through the history/physical exam, likely missing a lot because of nerves...and then I would have followed that up by serving up a half-baked plan to my attending (and I definately couldn't have done it with a student under my wing).
Now I find myself actually telling (very politely ;P) the attending what I'm going to do, where before I would "suggest" my plan. It's really a good feeling to see myself growing into the shoes that seem so big at times. There are moments when I'm walking by my hospital, when I gaze up at the tower that houses the patients. My hospital is expanding. Right next to the old tower is this shiny, new one...that is about 4 times as big as the old hospital. Looking at the two side by side, the leap of moving from that "small" hospital to a hospital that will be one of the largest in the country (maybe the largest) is daunting...that's how I feel when I look at myself in comparison to just the 2nd year residents (let alone full blown Attendings)...such big shoes to fill and I'll be expected to fill them sooner than I'd like. It comforts me though to remember those two hospitals, the difference between the two may be overwhelming, but my small, old hospital won't suddenly become that new, big one in a single night...it will grow into it one room at a time, one step at a time...until one day months, maybe years, later it will finally become that thing which it has for so long aspired to be.
Newbie Doc
Now I find myself actually telling (very politely ;P) the attending what I'm going to do, where before I would "suggest" my plan. It's really a good feeling to see myself growing into the shoes that seem so big at times. There are moments when I'm walking by my hospital, when I gaze up at the tower that houses the patients. My hospital is expanding. Right next to the old tower is this shiny, new one...that is about 4 times as big as the old hospital. Looking at the two side by side, the leap of moving from that "small" hospital to a hospital that will be one of the largest in the country (maybe the largest) is daunting...that's how I feel when I look at myself in comparison to just the 2nd year residents (let alone full blown Attendings)...such big shoes to fill and I'll be expected to fill them sooner than I'd like. It comforts me though to remember those two hospitals, the difference between the two may be overwhelming, but my small, old hospital won't suddenly become that new, big one in a single night...it will grow into it one room at a time, one step at a time...until one day months, maybe years, later it will finally become that thing which it has for so long aspired to be.
Newbie Doc
Sunday, October 17, 2010
Finding Out The Hard Way
I mentioned in my last post how there a lot of subtle body language cues and voice inflections that go into dealing with patients. I got to thinking about my rules in dealing with patients, my little pointers that I would pass on to someone going into medicine. I wrote a couple of them down. It will be interesting in a couple of years if my perspective changes on this. I may look back years from now and say how stupid or naive I was in writing this, but I feel right now like these are pretty solid ones.
1. Sit down and speak eye level with a patient, never talk down to them if you can help it.
You'll notice that some people are immediately confrontational if you stand there talking while looking down at them. It's much better if you find a chair or seat 2-3 feet from them at eye level.
2. Always explain; do it slowly and patiently (even if you don't feel that it needs done).
People often really appreciate it if you take 5 minutes out of your day to educate them on what is REALLY going on. I break it down very simply and explain what is causing there problem (if I understand it myself ;P), sometimes understanding a problem is as relieving as the medicine.
3. Don't use big words, speaking to a patient isn't the place to show off your education.
I had the displeasure of working under a doctor who would push his ideas and treatments onto people by saying big words. "Ohhhhh you've got Myotonic Dyskenesis...You should take my vitamin supplement." (He was more of a snake oil salesman than a doc). I don't really know if Myotonic Dyskenesis is a real disease, it's medical Latin for "muscles that move wrong". If you can help it never use medical words in conversation with a patient. Use it for naming the disease, don't use them in anything else and if you do, explain what they mean.
4. If you don't know, don't hide it, explain and tell them you'll find out.
Amazingly it's appreciated when you cop to your ignorance, it shows you know your limits, and patients trust you more for it. Just do your best to find out and you'll be great in their eyes. Plus it's much easier to me than trying to bury their question under a pile of BS and big words, which more Doctors do than you would imagine (not a ton, but more than their should be).
5. Fix your mask on tight even before entering the room. You never know what they will say.
A good portion of "being" a doctor is acting. Among your friends and family you are allowed to be yourself, but in a room with a patient, you must be non-judgmental, passive, and more mature than anyone you'd ever care to meet ;P I had to put stitches into a kids leg last night (huge knee wound, almost to the bone), sweat was pouring from my face as I did it...it was nervousness, but I asked the nurse very nicely to blot my forehead and I finished without incident. If that kid knew how nervous I was or if I had acted the least bit freaked out by his wound, none of what we did that night would have worked with him...the patient has to buy into you as the doctor or you can't help them (or at least not near as well).
6. Don't be afraid to show that you are human, just do it in a controlled and intentional manner.
If a patient tells me something horrible, I will empathize and acknowledge it, but it doesn't do the patient any good if you are overcome with emotion and can't do your job. Some might debate me on this.
7. When you don't know what to say, sometimes silence is the best answer.
I remember this mother finding out she had inoperable cancer in her stomach. I didn't have clue what to say. Something made me keep my mouth shut, but I sat with her and her husband as they cried, and when they were done, then we talked, but sometimes your silence and time is all there is to give.
I'm going to stop at 7, cause the others I can think of aren't that interesting (ie. how to sit when talking to a patient). But if I think of anymore I'll add to this and change it as my experience dictates. Thanks for listening guys.
Newbie Doc
1. Sit down and speak eye level with a patient, never talk down to them if you can help it.
You'll notice that some people are immediately confrontational if you stand there talking while looking down at them. It's much better if you find a chair or seat 2-3 feet from them at eye level.
2. Always explain; do it slowly and patiently (even if you don't feel that it needs done).
People often really appreciate it if you take 5 minutes out of your day to educate them on what is REALLY going on. I break it down very simply and explain what is causing there problem (if I understand it myself ;P), sometimes understanding a problem is as relieving as the medicine.
3. Don't use big words, speaking to a patient isn't the place to show off your education.
I had the displeasure of working under a doctor who would push his ideas and treatments onto people by saying big words. "Ohhhhh you've got Myotonic Dyskenesis...You should take my vitamin supplement." (He was more of a snake oil salesman than a doc). I don't really know if Myotonic Dyskenesis is a real disease, it's medical Latin for "muscles that move wrong". If you can help it never use medical words in conversation with a patient. Use it for naming the disease, don't use them in anything else and if you do, explain what they mean.
4. If you don't know, don't hide it, explain and tell them you'll find out.
Amazingly it's appreciated when you cop to your ignorance, it shows you know your limits, and patients trust you more for it. Just do your best to find out and you'll be great in their eyes. Plus it's much easier to me than trying to bury their question under a pile of BS and big words, which more Doctors do than you would imagine (not a ton, but more than their should be).
5. Fix your mask on tight even before entering the room. You never know what they will say.
A good portion of "being" a doctor is acting. Among your friends and family you are allowed to be yourself, but in a room with a patient, you must be non-judgmental, passive, and more mature than anyone you'd ever care to meet ;P I had to put stitches into a kids leg last night (huge knee wound, almost to the bone), sweat was pouring from my face as I did it...it was nervousness, but I asked the nurse very nicely to blot my forehead and I finished without incident. If that kid knew how nervous I was or if I had acted the least bit freaked out by his wound, none of what we did that night would have worked with him...the patient has to buy into you as the doctor or you can't help them (or at least not near as well).
6. Don't be afraid to show that you are human, just do it in a controlled and intentional manner.
If a patient tells me something horrible, I will empathize and acknowledge it, but it doesn't do the patient any good if you are overcome with emotion and can't do your job. Some might debate me on this.
7. When you don't know what to say, sometimes silence is the best answer.
I remember this mother finding out she had inoperable cancer in her stomach. I didn't have clue what to say. Something made me keep my mouth shut, but I sat with her and her husband as they cried, and when they were done, then we talked, but sometimes your silence and time is all there is to give.
I'm going to stop at 7, cause the others I can think of aren't that interesting (ie. how to sit when talking to a patient). But if I think of anymore I'll add to this and change it as my experience dictates. Thanks for listening guys.
Newbie Doc
No Hablo Espaniol
One thing that I wish I had done before going into medicine was learn Spanish. I've heard several different doctors bat around the statement that by 2030 the US will be predominantly a Spanish speaking population. That statement doesn't hit home anywhere else more than it does in clinic, where I would say I see about 1 English speaking patient for every 9 Spanish. To talk to a Spanish speaker I have to use a phone interpreter, which is not only a huge pain in the @$$, but also really decreases the level of care they get (not to mention the added cost to the clinic in using an interpreter). I can't hear the subtle inflections in a mother who is being abused, I can't tell when a dad is really worried about his kid and he's trying to hide it, and I can't relay my advice, my directions, and my health care nearly as good as I can with an English speaker. There is a lot of subtle body language cues and language inflection codes when dealing with patients and I miss a lot of those cues because I was stubborn. When I went through high school and college my thoughts on the subject were pretty one sided.
"They are the foreigners, they need to learn OUR language, not the other way around!"
Now that I'm seeing these patients every single day, to be honest, my thoughts on the subject hasn't changed much ;P. I still feel like they should learn the national language if they want to live and work here, but my view has changed in that I now see that it's less their fault and more ours. We (Government, Business, or whatever) are enabling it. I really can't blame them for wanting to come here, it's a better life. I would do the same for my wife and child (which is exactly what our ancestors did before us). I don't pretend to understand all the political under currents of what's caused this, but I can see the way the country is going and one thing I do comprehend is that I was an idiot for not learning Spanish ;P.
Newbie Doc
"They are the foreigners, they need to learn OUR language, not the other way around!"
Now that I'm seeing these patients every single day, to be honest, my thoughts on the subject hasn't changed much ;P. I still feel like they should learn the national language if they want to live and work here, but my view has changed in that I now see that it's less their fault and more ours. We (Government, Business, or whatever) are enabling it. I really can't blame them for wanting to come here, it's a better life. I would do the same for my wife and child (which is exactly what our ancestors did before us). I don't pretend to understand all the political under currents of what's caused this, but I can see the way the country is going and one thing I do comprehend is that I was an idiot for not learning Spanish ;P.
Newbie Doc
Saturday, October 16, 2010
Reading At Grade Level
I've had a rough week. Not so much in the amount of work I've had to do, but in the type of work I've had to do. My previous post dealt with an attending that for whatever reason had a problem with me. When it's someone irrationally berating or yelling at me, I find that easy enough to rationalize away and deal with...however, when it's someone very passively tearing me down, pointing out my every little error, and embarrassing me about in front of my co-workers, I find that much harder to deal with...but I manage. What's worse is that this attending has managed to find my greatest weakness in my medical skills regimen. What could that be? I'll be the first to say I am not an expert in any part of medicine, I'm in training and learning, but there is one part of medicine where I'm not much more skilled than a third year med student fresh out of the books. Could it be clinical knowledge? Procedures? Infectious Diseases?...nope...it's WELL CHILD CHECKS...I capitalize that for effect.
Well checks are when a parent or parents brings there kid in to clinic in order to make sure they are growing and developing normally. This is the appointment where I "simply" ask about eating, drinking, peeing, pooping, weight gain, smoking, drugs, abuse, car safety, child proofing, keeping poisons locked up, gun safety, proper sports wear, sun safety, sun screen use, nutrition, obesity, family diseases, and any questions or concerns the parents might have (I'm not including all the topics if I did this would be a much longer post). A seasoned doctor could talk about any one of these for half an hour...but you only have 15-30 minutes total for the encounter...so get busy and stay on point!
In medical school I always saw checking on a child that was "well" as something that was easy and so I ignored it. I took rotations that I considered exciting, rotations that were difficult, rotations where the kids were actually sick, thinking that I would take care of that "easy" part someday. As time went on I continued to push it aside and "get by". All the while neglecting a really fundamental part of pediatrics. In the end, I compare how I felt to how an illiterate adult must feel when confronted with reading. The longer you go without knowing it the harder it is to ask for help...the more embarrassing it is to not know how to do it...the more you dread it.
But in running into this particular attending, she wouldn't let me "get by" anymore. She grilled me on exactly what I was "checking". She did it in front of my friends...and I felt very, very stupid. I'm sure my face was flushed as she pointed out how disorganized my approach was, how poorly I questioned, and brought up my pathetic attempts at anticipatory guidance (car seats, child proofing, etc). It's times like these when you feel like someone is antagonizing you. You can choose to say "Screw You"...and I REALLY wanted to say it. But there is this "wise man" proverb from some book I read in childhood that has always stuck with me...the idea at least, I may be butchering the wording.
A Wise man seeks out advice and a fool despises it.
I think it stuck with me because I'm often too proud and too often don't have the skills or ability to back up that pride. That quote has saved me countless times, times where I felt embarrassed, where my pride told me to shut my ears and close my eyes, but then that thought would strike me like an arrow, and it would give me the strength to grit my teeth and open them.
That's what happened this last week. I realized that she was right and since my last post all I have chosen to do is those dreaded, damn well child checks...embarrassing as it is to have me friends see me slowly, painfully stutter through them day in and day out. It has seriously been such a depressing and dull week. I can't count the number of times I saw two patients one with something exciting in the header like "seizures" or "blood in stool" and instead I would choose the one next to it saying "Well Child Check"...it's been a very humbling two weeks, but I console myself in knowing that every day I get a little bit better and my weakness gets a little bit stronger...someday soon I'll be "reading at grade level".
Newbie Doc
Well checks are when a parent or parents brings there kid in to clinic in order to make sure they are growing and developing normally. This is the appointment where I "simply" ask about eating, drinking, peeing, pooping, weight gain, smoking, drugs, abuse, car safety, child proofing, keeping poisons locked up, gun safety, proper sports wear, sun safety, sun screen use, nutrition, obesity, family diseases, and any questions or concerns the parents might have (I'm not including all the topics if I did this would be a much longer post). A seasoned doctor could talk about any one of these for half an hour...but you only have 15-30 minutes total for the encounter...so get busy and stay on point!
In medical school I always saw checking on a child that was "well" as something that was easy and so I ignored it. I took rotations that I considered exciting, rotations that were difficult, rotations where the kids were actually sick, thinking that I would take care of that "easy" part someday. As time went on I continued to push it aside and "get by". All the while neglecting a really fundamental part of pediatrics. In the end, I compare how I felt to how an illiterate adult must feel when confronted with reading. The longer you go without knowing it the harder it is to ask for help...the more embarrassing it is to not know how to do it...the more you dread it.
But in running into this particular attending, she wouldn't let me "get by" anymore. She grilled me on exactly what I was "checking". She did it in front of my friends...and I felt very, very stupid. I'm sure my face was flushed as she pointed out how disorganized my approach was, how poorly I questioned, and brought up my pathetic attempts at anticipatory guidance (car seats, child proofing, etc). It's times like these when you feel like someone is antagonizing you. You can choose to say "Screw You"...and I REALLY wanted to say it. But there is this "wise man" proverb from some book I read in childhood that has always stuck with me...the idea at least, I may be butchering the wording.
A Wise man seeks out advice and a fool despises it.
I think it stuck with me because I'm often too proud and too often don't have the skills or ability to back up that pride. That quote has saved me countless times, times where I felt embarrassed, where my pride told me to shut my ears and close my eyes, but then that thought would strike me like an arrow, and it would give me the strength to grit my teeth and open them.
That's what happened this last week. I realized that she was right and since my last post all I have chosen to do is those dreaded, damn well child checks...embarrassing as it is to have me friends see me slowly, painfully stutter through them day in and day out. It has seriously been such a depressing and dull week. I can't count the number of times I saw two patients one with something exciting in the header like "seizures" or "blood in stool" and instead I would choose the one next to it saying "Well Child Check"...it's been a very humbling two weeks, but I console myself in knowing that every day I get a little bit better and my weakness gets a little bit stronger...someday soon I'll be "reading at grade level".
Newbie Doc
A Rat In A Cage
1. Have you ever felt you should Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
This is the C.A.G.E. questionnaire. This is one of the screens my colleagues in adult medicine use to check for problem drinkers. If you answer yes to 2 or more of these questions, it's very likely that you have a drinking problem, that you are addicted. Now insert your own addiction. Do you have one?
1. Have you ever felt you should Cut down on your ________?
2. Have people Annoyed you by criticizing your ________?
3. Have you ever felt bad or Guilty about your ________?
4. Have you ever had a ______ to steady your nerves or get over something stressful (Eye-opener)?
I do. It's not something that is as destructive as a drug addiction, but it's detrimental to my life. It's an addiction that I can get caught up in for hours upon hours. When I'm at my worst I let homework go overdue, blogs don't get written, bills get paid late, my wife is neglected, and life, in general, passes me by. I think those who know me, know what my little problem is and that I struggle with it. The reason I'm able to write this blog tonight is because I had my wife lock up this little habit and hide the key...I'm not strong enough to totally get rid of it...like most addicts I have an excuse to keep it around...and I'm worse for knowing it's an excuse. Maybe you'll see a few more blogs on here now that I've temporarily "fixed" my little problem. You might even get to see first hand my withdrawal...it's funny that I actually have them, but apparently I do, according to my wife. I once got totally rid of this habit for months on end and she said I was so dull and "mope-y" that she bought me another...to which I am presently hung up on. Am I really like the alcoholic that isn't as "fun" when he/she is sober? It's just video games...why the hell am I so pathetically attached to them...I know it's pretty lame...I'm working on it (why, when I say that, do I feel like the hundred thousand smokers that I've heard say "I'm trying to quit").
Newbie Doc
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?
This is the C.A.G.E. questionnaire. This is one of the screens my colleagues in adult medicine use to check for problem drinkers. If you answer yes to 2 or more of these questions, it's very likely that you have a drinking problem, that you are addicted. Now insert your own addiction. Do you have one?
1. Have you ever felt you should Cut down on your ________?
2. Have people Annoyed you by criticizing your ________?
3. Have you ever felt bad or Guilty about your ________?
4. Have you ever had a ______ to steady your nerves or get over something stressful (Eye-opener)?
I do. It's not something that is as destructive as a drug addiction, but it's detrimental to my life. It's an addiction that I can get caught up in for hours upon hours. When I'm at my worst I let homework go overdue, blogs don't get written, bills get paid late, my wife is neglected, and life, in general, passes me by. I think those who know me, know what my little problem is and that I struggle with it. The reason I'm able to write this blog tonight is because I had my wife lock up this little habit and hide the key...I'm not strong enough to totally get rid of it...like most addicts I have an excuse to keep it around...and I'm worse for knowing it's an excuse. Maybe you'll see a few more blogs on here now that I've temporarily "fixed" my little problem. You might even get to see first hand my withdrawal...it's funny that I actually have them, but apparently I do, according to my wife. I once got totally rid of this habit for months on end and she said I was so dull and "mope-y" that she bought me another...to which I am presently hung up on. Am I really like the alcoholic that isn't as "fun" when he/she is sober? It's just video games...why the hell am I so pathetically attached to them...I know it's pretty lame...I'm working on it (why, when I say that, do I feel like the hundred thousand smokers that I've heard say "I'm trying to quit").
Newbie Doc
Wednesday, October 6, 2010
Eh..I've Got Enough Friends Anyways ;P
I can't say that I really like my outpatient clinic that much yet maybe things will change, but I got a bad vibe going in. I had heard as much from older residents...I believe the quote was, "There is WAY to much estrogen running through that place and that's coming from someone who has estrogen." I honestly don't mind things to much except for one attending in particular, she's a lot like my fourth grade teacher who used to send me to the principles office all the time way back when. She's just really "catty" and aggressive...and you never quite know when she's gonna hit you with it, so you have to be in a constant state of increased awareness...which is exhausting and demoralizing...you think she's being nice, but she's really just lulling you into a false sense of security then...WHAM!!! Even my fellow co-workers have noticed that she doesn't like me...it's really weird, I don't usually rub people the wrong way but when I do, it's like I can't do anything but continue to push them...not necessarily on purpose...it's kinda like when someone tries to grab you and push you off balance, you either fall or you instinctively reach out and grab their arm...simultaneously keeping yourself up and tossing them in the water. Today she was speaking on a particular vaccine. She was speaking about how you couldn't give a particular vaccine after you had administered a totally different treatment for a completely different virus...this on the surface doesn't make sense and I simply asked her to clarify...instead of clarifying she told me to "THINK about it" (not in a nice and non-judgmental tone)...I told her, "if thinking about it would get me an answer then I wouldn't have posed the question in the first place."...she didn't like that response. I finally figured it out, without her help. To multiply the badness, later in an effort to make peace I asked her a question that I figured she would know the answer to. She had been harping on how important it was NOT to get these two very similar vaccines mixed up...she had said, "if you mix up the Tdap and the Dtap vaccines, you will FAIL this rotation." Thinking that this would be an obvious question to pose and one she had to know the answer to, at the end of the lecture, when the teacher asks, "Does anyone have any questions?" I wanted to show her that I had been listening, so I asked this seemingly very simple question. Not because I knew the answer, but because I figured if she were going to beat on something so much, that there must be a very good reason to go on about it. So I asked, "What's the big deal with switching up the Tdap and the Dtap? Does something bad happen?"...in retrospect, it probably looked like I knew what the answer was, because I asked it so pointedly, and I was setting her up to look stupid...but that wasn't my intention...regardless, it worked out that way when she stumbled and looked for help from her fellow attendings (I thought to myself "OH $%@!, here we go...") and I caught a couple of my fellow interns grinning just out of her eyesight....I hope it was out of her eyesight anyway. I haven't found a good way to deal with these types of people yet, my routine when I meet someone that is just constantly irritated by me is to treat them as best you can and try not to get into a tennis match of meanness...sometimes it happens though despite your best efforts and when it does it's another one of those things where you've just got to take it one step at a time.
Newbie-Doc
Newbie-Doc
Tuesday, October 5, 2010
Greener Pastures
I'm back! This morning I didn't have to get up at 5am. Life is looking up. I was able to wake up WITH my wife this morning and actually take my time getting ready. I was in grid lock traffic with the rest of the world but somehow nothing seems to effect me because I'm done with the rotation that shall-not-be-named. It truly is a horrible month. I actually stayed 3 hours later than I was expected to yesterday to help out the new interns that were coming on...I felt bad for them...it took me right back to my first week there and how quickly I was beaten down, I felt obligated to help them through it a bit. I knew that I would catch some hell for it, but really all I got was people asking me, "DO you SERIOUSLY like being here?!?!" and "DUDE, what the HELL are you doing, ESCAPE!" But that was from my seniors...who I was also helping out. It was easier working when I knew I didn't have to be and that my friends would benifit a little bit. I'd be lying though if I didn't say what I'm going to say - having a good reputation is key when you work on a team. You want to be the guy or girl that people can turn to over and over again for help in solving problems...it seems like more work and it is in a way. But it puts people in your corner and when its YOU that needs the help (which any resident can appreciate...especially me). Anyways I eventually did leave that place and when I left, I left with a clear conscience knowing that I had given my friends the best start I could...and now I'm on to greener...later starting pastures (ie. Outpatient Clinic!!!!).
I won't totally hate on that place though, I have to say that leaving that place I'm a far stronger doctor than I was going in. The place wasn't hell because of the people or the paper work or any other reason that people normally hate work...it was hell because of the sheer volume and complexity of my patients...it was a hell, but it was a hell that I chose and I wanted and when the time comes, I'll go back to it willingly...but I need a break first :)
Newbie Doc
I won't totally hate on that place though, I have to say that leaving that place I'm a far stronger doctor than I was going in. The place wasn't hell because of the people or the paper work or any other reason that people normally hate work...it was hell because of the sheer volume and complexity of my patients...it was a hell, but it was a hell that I chose and I wanted and when the time comes, I'll go back to it willingly...but I need a break first :)
Newbie Doc
I'm So Sorry
I was actually told once that the letters "MD" mean never having to say you are sorry. There is that stereotype that the public has. That being a doctor means you are "less human" than others, that you make less mistakes, and that when errors do happen it wasn't the doctor's fault. Like hearing Superman apologize for not being able to save a bystander from a flood or an exploding volcano...you never see him apologize in the comics for something that was actually HIS fault. As doctors there is that idea, that somehow we are similar to this, but in my experience at least, I have found that I am still very much human and prone to the same errors of poor logic and dumb mistake that I was susceptible to before I became an MD. I think I had this thought in the back of my head that when they handed me my diploma I would somehow change and instantly become this infallible super-human figure...but it's just like when they ask you if you feel any older on your birthday...you don't.
Even still, it's this feeling that you shouldn't apologize that I struggle with. I think you could take the most kind and considerate person on the planet, place them in the shoes of a doctor, and even they would struggle with apologizing to a patient. Every single time that I say the words "I'm sorry..." to a patient, my mind mentally pauses and I feel guilty. I think the guilt stems from that idea that doctors don't apologize because doctors don't make mistakes and from the idea that I shouldn't have made the mistake period...maybe also a little bit because I feel like I'm opening myself up to litigation ;P (but really more for the latter reason). You have this thought that when you admit to a mistake or an incorrect course of action that they will tear you apart, that they will fire you from their care, or that they will not trust you (and that may happen) but it won't happen near as fast as it does if you refuse to communicate with your patients and if you refuse to admit your mistakes to others.
I recently had to apologize because I hadn't communicated how poor a prognosis this little 12 year old girl under my care had. I honestly just assumed they knew how bad it was and I let it catch them and me off guard when they realized that she was going to stay the way she was for possibly the rest of her life. The girl who I speak of is an eleven year old who is currently bed bound from a infection of the brain that went untreated too long. The hospital received her from an Indian reservation where medical care was poor. She isn't improving, she won't be improving, she is actually getting worse. The parents are frustrated, the medical plan is not changing, and my attending after discussing what our patient's course of care is likely to be (chronic, unremitting, dismal - seriously pick a word - the clinical prognosis SUCKS for this kid), with tears of frustration hanging in the mother's eyes his words are, "I can see that you are impatient mam, I can see the frustration in your eyes, but this is how it's probably going to be for your daughter for the foreseeable future." He then coldly walks from the room without another word. I then spent the next 40 minutes speaking with the parents and a lot of that speaking involved saying that I was sorry. Sorry that we couldn't do more. Sorry that I hadn't updated them frequently enough and that they had felt surprised by this statement of prognosis. Sorry that their daughter is dying and there is little we can do. I honestly admitted to them one of the reasons I hadn't spoken directly of her prognosis was because I didn't want to be the one to say it...which was more than a little true...I should have though, I knew them best. Having me state the tell them in two words would have been better than what we had done to them just then. I let them down.
In horrible moments like this, moments even Supes could not bear, he would go back in time by flying around the world rediculously fast (like the movies), he'd go back, and give the child antibiotics and this little girl would be running around causing trouble with her friends present day...but she's not playing with her friends...she's laying there in a diaper, with a hole in her neck, and a tube in her stomach...she's laying there with an unblinking stare. She and I share a terrible truth which the parents are now beginning to realize as well...there is no Superman, it's just me and all I have for them is my pathetic apologies. I'm so sorry.
Newbie Doc
Even still, it's this feeling that you shouldn't apologize that I struggle with. I think you could take the most kind and considerate person on the planet, place them in the shoes of a doctor, and even they would struggle with apologizing to a patient. Every single time that I say the words "I'm sorry..." to a patient, my mind mentally pauses and I feel guilty. I think the guilt stems from that idea that doctors don't apologize because doctors don't make mistakes and from the idea that I shouldn't have made the mistake period...maybe also a little bit because I feel like I'm opening myself up to litigation ;P (but really more for the latter reason). You have this thought that when you admit to a mistake or an incorrect course of action that they will tear you apart, that they will fire you from their care, or that they will not trust you (and that may happen) but it won't happen near as fast as it does if you refuse to communicate with your patients and if you refuse to admit your mistakes to others.
I recently had to apologize because I hadn't communicated how poor a prognosis this little 12 year old girl under my care had. I honestly just assumed they knew how bad it was and I let it catch them and me off guard when they realized that she was going to stay the way she was for possibly the rest of her life. The girl who I speak of is an eleven year old who is currently bed bound from a infection of the brain that went untreated too long. The hospital received her from an Indian reservation where medical care was poor. She isn't improving, she won't be improving, she is actually getting worse. The parents are frustrated, the medical plan is not changing, and my attending after discussing what our patient's course of care is likely to be (chronic, unremitting, dismal - seriously pick a word - the clinical prognosis SUCKS for this kid), with tears of frustration hanging in the mother's eyes his words are, "I can see that you are impatient mam, I can see the frustration in your eyes, but this is how it's probably going to be for your daughter for the foreseeable future." He then coldly walks from the room without another word. I then spent the next 40 minutes speaking with the parents and a lot of that speaking involved saying that I was sorry. Sorry that we couldn't do more. Sorry that I hadn't updated them frequently enough and that they had felt surprised by this statement of prognosis. Sorry that their daughter is dying and there is little we can do. I honestly admitted to them one of the reasons I hadn't spoken directly of her prognosis was because I didn't want to be the one to say it...which was more than a little true...I should have though, I knew them best. Having me state the tell them in two words would have been better than what we had done to them just then. I let them down.
In horrible moments like this, moments even Supes could not bear, he would go back in time by flying around the world rediculously fast (like the movies), he'd go back, and give the child antibiotics and this little girl would be running around causing trouble with her friends present day...but she's not playing with her friends...she's laying there in a diaper, with a hole in her neck, and a tube in her stomach...she's laying there with an unblinking stare. She and I share a terrible truth which the parents are now beginning to realize as well...there is no Superman, it's just me and all I have for them is my pathetic apologies. I'm so sorry.
Newbie Doc
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