The most embarrassing moment of third year

I was thinking back on all the funny moments of my medical school clerkships, and the one that always sticks out is this one girl I saw on Peds. She was like 16. She had a rash on her right flank and abdomen, with itching, that had been there for a week. There was one spot that was big, and there were smaller lesions that followed skin lines. For all you medical students, say it with me: pitryiasis rosea. Anyway, she lifted up her shirt to expose her side and I got a pretty good look at the Herald spot. However, her mother, in the interest of furthering medical knowledge, was unsatisfied with this level of exposure. Perhaps she was a surgeon in a previous life, but she was determined to have complete exposure. So, she walked over and yanked her shirt up past her breast and pulled her shorts down to her pubic bone. And to the mom's credit, I visualized the entire extent and distribution of this girl's rash, from base of right breast to right inguinal region, extending along the back as well. I imagine that I probably turned some odd shade of purple, muttered something, and left.

You know what the scary thing about being a doctor is? You'll be sipping a mocha, and the guy at the table next to you, he clutches his chest and falls to the floor. Someone yells out to call 911 and asks for help, that's you. And when you're sitting on the porch and you see some guy fall off his bike and smack his head on concrete, and he needs help, that's you. And when you see a car swerve off the road and flip a few times, you gotta pull over, because that person needs you.

There's a nice feeling of anonymity before all of this med school stuff. I could watch an ambulance drive by with its lights going and think to myself how glad I was that it had nothing to do with me. I could see an accident and think, I'd better let the professionals handle this. The only problem with that attitude is that in a few months, I'll be the professional. And it'll be 3AM and I'll get a page from a nurse telling me that Mr. D in 5142-2 had a 30 second run of V Tach. And I can't walk away. That's a scary thought.

My type of girl

I've spent a lot of time lately giving thought to something a friend of mine told me. She informed me, routinely, that not only do I have a type (of girl) but that this girl I was chasing after certainly wasn't my type. This sort of set off a series of thoughts, revolving around the question: what is my type? So, it's been years since that statement, and I think that only recently am I in any way grasping what my type is. And it's sort of a sad realization, because now that I know what my type is, it sort of points out all those women that I've known and that have summarily written me off. You know, sometimes knowing what you want is more painful because you are made acutely aware of the fact that you don't have it. Whereas if you don't know what you want, you don't know what you're missing.

Anyway, that's not to say I'm depressed or all 'pity me' or whatever. I just made the observation today. At least I've had plenty of time to think about what is not my type, and that list is pretty extensive. And it's funny, because I always find myself in a funny spot where I'm sure that I should want something, but I don't. It's just not a deal to me in the least. I guess there are perks to knowing what you want. You don't waste your time on what you don't want. Or if you do, you at least have the good sense to know you're being an idiot.

Fuck them too

So, 4 weeks ago, I had my last cigarette. This is something that most people would be proud of. I feel no pride in this whatsoever, because it was terribly easy. I'm not really addicted to nicotine. My deal with cigarettes is that it's how I dealt with a world that seemed to screw me over at just the right times. It was my means of shortening my life, a suicide that would take 40 years.

But I'm learning how to deal with life again. I'm figuring out that my life's been in neutral for so long that I've been rolling backwards. It's time to get things in gear again. I know this sounds incredibly stupid. I feel stupid for typing it, but here goes. Why am I so down on myself? Honestly, despite my tremendous string of failure, I'm a good guy. I'm pleasant, courteous, kind-hearted. I'm honest, eager, driven. I'm not ugly or freakish. I take good care of myself. I am, all in all, a pretty decent guy. Why should I worry so much about dating and women and all that jazz? Honestly, if no women in this city or this state can see their way to dating me, fuck them. If no women in this city or this state can see themselves dating some Asian guy, fuck them too.

Why should I get all worked up about the hangups of other people? Why should I torture myself over what is essentially someone else's problem? Heck, I'm not going to lose another second of sleep over this shit. You know, if no one can appreciate me, I shouldn't have to change myself or lower my standards. That's bullshit. And if it takes another 26 years of my life to find someone that appreciates me for who I am, then so be it.

It's amazing how much more empowered one can be when one concedes reproduction.

San Diego must be nice this time of year

I'm finally submitting my ERAS application. It took me long enough. I'm applying to an obscene number of programs, especially since I'm very much leaning towards staying right where I am. It was funny today. I had two different attendings tell me that they didn't even need to see my app. One attending asked when I was interviewing. I told him that I hadn't even submitted my application yet. He kind of laughed and said for me, it wasn't necessary.

I would like to stay here for residency. There are all sorts of reasons I shouldn't stay here. It's always a good idea to train at a different location so that you can see a variety of conditions and managements. It'd be nice to go to a program where I can get a nice fellowship and a good faculty position. It'd be nice to work at an institution that runs more efficiently. But what it boils down to for me is that if I stay here, I know it's going to be another 3 years where my romantic future will go bbbpllbffplt.

I'd like to believe that it wouldn't make a difference where I am. I'd like to believe in fate and destiny and finding that perfect person for you. Except I know that fate and destiny and all that stuff is bullshit. I know that if I plan on procreating, I have to go to the East or West Coast. But I can't stand the idea. I can't stand the thought that my ability to attract another human being is entirely dependent on geography.

You know, it's amazing just how low you can set your sights in life. I used to think that what I wanted was someone who was perfect for me, who could understand me, who loved me, who I could share my life with. At this point in my life, my romantic aspirations total to this: I'm looking for a girl who will let me feel her up occasionally.

Finding your calling

The perks to being on a consultation service are getting to see very bizarre things that you'd otherwise never see. You see things like Lown-Ganong-Levine (LGL) syndrome. That's a one in a million. Of course, it's bad for the patient. LGL is a pre-excitation syndrome similar to WPW, except there are no delta waves on the EKG. Essentially, you have to have one hell of a clinical suspicion to find it.

My scleroderma patient from last year is in house again. I want to pop in and say hi, but I feel bad. I mean, I have no relationship with her. It's not my place to pop in. Sometimes, medicine is so confusing. I spend so much time caring, but then when they're off my service, I have to force myself not to care.

Today, while my attending was writing his note, I asked one of the surgery residents about another patient we'd done a consult on. My attending turned to me, and listened to me blather on about this guy because he'd made such an impression on me. I can't help it sometimes. I really like patients. I like meeting them, taking care of them, patching them up, trying to help them out. All that time in pathology and radiology, it can't even touch the feeling of meeting someone and helping them get better. I can't imagine doing something like radiology for my life.

But that's the cool thing about medicine. We somehow find our way to the right spot. I managed to find my way to internal medicine. While all my friends are interested in cardiology or rheumatology, or things like radiology or ortho, I find myself more and more driven towards general internal medicine. The funny thing? Some people tell me that I must be crazy. Internists are a dying breed. Internists are being eaten out from above and below. Internists are slowly becoming either hospitalists or else glorified family docs. And then, the idea of doing academic medicine, that's just nuts.

But on the other side, I get so many good responses sometimes. You know, I had one attending tell me that I should definitely do academics, because teaching is a desire that few people have. Most academic physicians teach enough to be faculty, but their primary aim is research. Even the chairman is research driven, and I think the chair is one of the best teachers in the department. The thing is though, I get so pumped over simple things. I get flat out excited about showing someone how to write up an H&P. I taught one student the basics of EKGs and it was just fun. You know, THAT is finding your purpose in life. THAT is finding your calling. You know you're in the clear when you spend 30 minutes of your life teaching someone a piece of information they may forget in 5 minutes, but you feel good about it.

I really hope that I will eventually find myself in academic medicine. I probably won't be at one of the star institutions, because I don't want to waste my time with benchwork or strict research. I can't write a grant to save my life. What I want is the teaching. Let the other guys do all the research. I want to get my hands on some third years and show them what medicine means to me.

And at the end of the day, when you look at yourself in the mirror, it's nice to know that you did good. Who else gets to go home and say to himself, I didn't give them a fish, but I taught them how.

Teaching rounds

Don't you just HATE when you know something, but something in your head is convinced that you must be wrong, so you go against everything in your body and say the answer you know is wrong, but you manage to convince yourself it may be right. Well, I did that today. I read an EKG ALL WRONG, and I know better, dammit. I know fucking better than that. C'mon. You gotta step up to the plate. This ain't the bush leagues no more.

It's funny when I work out. My workout is an exercise in self-deprecation. It's all, 'What are you doing? Get this fucking weight up. Get it up. You're a wimp. You're a piece of shit. You're nothing. You're small time. Get that FUCKING weight up.' I've only lost 3 lbs since the end of surgery. That's 3 lbs in 3 months, but I'll tell you what, I'm probably as healthy as I've ever been in my life. I feel like a million dollars. I feel like I'm finally not a hypocrite when I tell my patients to eat healthy and exercise.

I have never had so much fun as I have had in the past couple weeks teaching 3rd years. I can't think of anything that has thrilled me as much as teaching someone about medicine. What a wonderful reward it is that one cannot help someone else without helping oneself. If ever I had a goal in life, it's academic medicine. The doctors I've worked with tell me that I'm an oddity. Who wants to do general internal medicine in an academic setting? That's nuts. And moreover, I don't want the research, but I want to teach! I must be crazy. Well, folks, if crazy is teaching and loving it, then crazy I am.

I have some friends that tell me that they'd like someone like me as their primary care doctor. I find that amusing, because that's a pretty awesome responsibility. However, I certainly can understand what they're saying, because I think the same thing about some people that I know. I think, wow, it doesn't matter if they're not the smartest or best. They've got the drive. They've got the talent to be a fantastic doctor. They've got the heart to do this for all the right reasons. I think if I had to choose a new primary care doc from the guys in my class, it'd be a pretty easy choice.

I read through my evaluations from my medicine rotation, and I felt good because I felt that all the evaluations were pretty thoughtful. I know this because they all gave me high marks in professionalism and rapport. It's true. I'm not the smartest. I don't do a good job with data collection. I don't always think things through. But I'll tell you what. Every single one of my patients recognize me, know what service I'm working on, and aren't surprised when we come by to round. They all know more about their conditions than when they came in, and I still remember most of my interesting patients by name. Now, I just got to get that whole diagnosis and treatment stuff down...

Consulting service

Why do people consult without doing the basic work? I mean, you call in the experts when you don't know what's going on. You shouldn't need to call in the experts to hold your hand through the basic steps. We all go through medical school. We all know the basic stuff. You know, if you consult a cardiology service and you don't do an EKG, you should be shot. I don't feel guilty at all paging the shit out of these surgery residents. They consult my service without telling us why, without telling us what surgery they're going to do, without telling us when they're taking the patient to surgery, without telling us anything. Two consults I did today were consults on empty charts. What's the point of that? I have to do all the work. I'm doing THEIR work. It's aggravating.

When I was on vascular surgery and we were consulted by medicine services, we'd come by and there would be blood cultures ordered, chest x-rays shot, and all the appropriate labwork done. Now that I'm on a medicine service being consulted by everyone else, it's appalling how shoddy the consults are. You know, I was consulted yesterday basically for a 'Please find the old records and read them.' We did nothing except request old charts. I guess Friday is always a bad day in the hospital. Oh well.

The thing is though that consultation is a request to another physician formally to help with the treatment of a complicated patient. It's admitting that you need some assistance. That is the purpose of consultation. It's not to offload work. It's not to have someone else doing the stuff you don't want to do. It's not to have someone pat you on the back. I get frustrated when people write for consults and they don't want a consult. They want to have someone else do the work, or they want someone to congratulate them. I am interested in neither. Having done several consultation services, I've come to the conclusion that the ideal consult is one where the work is already done. It's not that I'm lazy. It's that it's flat out rude to make someone redo all the work that's already been done (or do all the work that should've already been done). It's rude to consult someone and make that person reinvent the wheel just to figure out what's going on.

One of my friends is a resident. When I was on vascular, he was on the heme/onc medicine service, and he consulted us over a possibly infected port that we'd put in. I go down to do the consult, and he's already done a chest x-ray, blood cultures, wound cultures, CBC and BMP. All my attending had to decide was if he wanted it out, and when and where to do it. Of course, it would come out. That's what a consult should be. I told my friend that the consult I did with him was the perfect consult, the ideal way a consultation service and an admitting service should interact. It shouldn't be going up to the floor, finding a chart with a sloppy and scant H+P with no old charts and nothing else in the chart except nursing notes. Half the time, I find myself asking why we were consulted. There's no reason provided.

I really enjoy working with students. But I do get frustrated by people who are gifted with a big ole brain, and refuse to use it. You know, one of my surgery attendings put it to me. I told him I didn't know the answer to his question, and he refused to accept that. "No, you're smarter than that. You don't get off that easy." and he grilled me, and I got the answer, and it was the best learning experience I've ever had. And it was because he made me rise up to another level. And I'm not really asking anyone to even do that.