Experience points

I get a lot of hits from a link in this pre-medical student forum, and reading through it, I was actually quite horrified. My Don't Become a Doctor series is all about the downsides of the practice of medicine, but I didn't think people were actually sitting down and calculating the costs, trying to balance out MBA vs JD vs MD. A word to the wise, DDS wins that contest every time.

The prevailing argument throughout the forum revolves around whether physician compensation is adequate to defray the costs of medical school and residency. I think that you can add and subtract all the dollar figures you wish, but that's not the cost of medicine.

The real cost of medicine is not that I will make only ~$130k as a general internist. The cost to me is that from the age of 21 to 29, I was doing nothing but studying and working. My friends got jobs, got married, bought houses, and in some cases had kids. I did none of these things. My single friends spent their evenings hanging out in the social scene, developed big networks of associates. I don't know anyone outside of health care.

Undoubtedly, you'll say that there are plenty of docs who got married in med school, had kids in med school or residency, and have all the things that I mentioned: a wife, a home, a family, a big network of friends and social support. This is true. But do you think any of those new spouses or new parents wanted to spend 80 hours a week in the hospital away from their families? Many of my friends with kids never saw their child's first words or first steps. As I like to say, one of my colleagues celebrated the birth of his child by taking an afternoon off. I tell people this jokingly, but it's true. He took a half day.

Who cares about the money? Medicine cost me my twenties. I can't put a dollar figure on that. While other people were backpacking Europe, I was scouting out the best spot in the library to study. While everyone else was amassing a treasure trove of experience points and leveling up, I've been sitting at lvl 1.

If you ask me today if it was worth it, I'll say yes. I am doing something that I love, and I am getting paid handsomely for it. I have reached a point in my life where I am finally reaping the benefits of all that sacrifice, but the thing about sacrifice, you have to give up something good to get something good.

Shiny new toys

CLK + wind turbine by Jasmic

Someone in my hospital bought a new Mercedes CLK AMG convertible. It's almost a crime to be driving it outside in the weather we've been having. Still, it's managed to keep its shine, despite some mud splatter and water spots. I saw it in the physician parking area while I was heading in, and I couldn't help but stop and gawk.

One of my colleagues spotted me in the parking lot and caught up to me. He saw what I was looking at and whistled. "Man, that's a beautiful car." We both stood there for a while, in awe of such a fine piece of German engineering.

When I became an attending, I bought a fancy car. It wasn't too fancy, but certainly was not entry level. In the parking lot, it's very respectable, but clearly shows that I am not a subspecialist. I have nothing to be ashamed of. Considering my salary, it's quite a nice car, but my car's sticker price isn't even half of the CLK AMG cabriolet. This person laid out near $90k and is driving it in winter weather in the Midwest.

Every now and then, I think that I could be making more money. I could be working better hours. I could have an easier life. I have certainly earned it. And when I see something so gorgeous, that I can probably never own, it hurts sometimes. I think my colleague saw me comparing the Mercedes to my car.

"Y'know," he noted. "It's too bad that you can't judge a physician by the car he drives. Then it'd be really easy to find a good doctor." We both got a good chuckle and headed inside.

One of the things that I realized during medical school is that the value of something can seldom be measured with dollars. Doing something I love, that is worth a CLK AMG Mercedes. It's worth a Lamborghini Murcialago. It's worth an Aston Martin DB9. It's worth far more to me than 4 wheels and some metal. I can't really quote scripture and verse, but there is one line from Isaiah (55:2) that I like: "Why spend your money for what is not bread; your wages for what fails to satisfy?"

Sure, I'd like a fancier car and a bigger TV and a fancy house. I'd like a lot of things. But at the end of the day, they are things. And things cannot bring happiness. Joy is doing, not owning.

Attending physician

I haven't written much about being an attending. Partly that is because I don't want to reveal who I am, but also, I feel like being an attending is a hard thing to get a good grip on. In some ways, it feels fantastic to be done with training, but it seems like it's actually quite a bit more stress.

As a resident, I had interns below me and attendings above me. There were tons of people whose job it was to question every decision I made. There were other residents around who could provide some input. As an attending, it's just me. There's no one else. It feels quite odd not having to run my decisions past someone else. After my first clinic, I grabbed one of my colleagues and talked about my patients. "Why are you telling me this?" he asked. It just felt so alien to make a decision and not have it questioned.

I feel like an acrobat without a safety net. I know what I'm doing. Heck, I'm board certified. But being an attending is an isolating experience. I miss having someone tell me that I'm doing the right thing. Now, I have to question my own decision making. I sit at home at night asking myself, "Did I really need that stress test?" Worse yet, I've already had a couple mortalities, and I can't blame anyone but myself.

But for those of you slogging through residency, let me tell you that on balance I am very glad to be an attending. All this time, all the work, and now I am the one calling the shots. That has a price, and sometimes I don't call 'em right, but now they are my mistakes to make, and that is both scary and wonderful.

This was supposed to be the post where I shit all over emergency medicine

I wrote a really long, really bitter tirade about my problem with some emergency physicians. It started out as part of the 'choosing a specialty' series, but I realized that my tirade had nothing to do with actually choosing a specialty, but was just my bitterness.

My complaints were not really about ER docs in particular, but were more about doctors who don't care enough to do a decent job. Every field has its flaws. ER is not exceptional in that respect, and it would be unfair for me to single out ER. Someone could write an equally bitter tirade about internal medicine. And in fact, when I was a senior resident, I was far more harsh with my interns who were lazy or tried to pass off substandard work, to the point where I earned a reputation as a hardass.

Maybe an example would make my point better. A friend of mine in the ER, Black Cloud, he is the worst of luck. When I was a resident, he would give me the most admissions, and always the most acute. It was a nightmare every time he was on. But BC always charted accurately, ordered the appropriate tests, and communicated with me personally. I knew that even the sickest patients he called to me were receiving the best care he could provide.

Contrast this with Phoning It In. PII would do whatever it took to avoid work. Charting wasn't done. Appropriate tests not ordered. Consults not called. Cases would be dumped on other ER docs incomplete, and when I came to admit, they had no idea what was going on because PII hadn't given signout. I've had patients of PII's whom I've intubated upon walking into the room because they were seconds away from respiratory failure.

PII was a tremendous white cloud, and calls were easy, but if I had to choose between PII and BC, I'd go with BC every time. Even though the calls were tough, I knew that BC was doing everything he could to take care of his patients. And that's what loving your job is all about.

I will close with this parting shot. I got a LOT of attitude from some (certainly not all) of the ER residents when I was the on call IM resident. They would tell me that IM is cupcake, and imply that they could do my job without breaking a sweat. They would order me around like I was their servant. "You need to admit this guy in 5. The chart's over there. Pfft, I don't know his name, look at the chart! Jeez." This is a direct quote. My favorite call for admission was, "You need to admit this patient. What's wrong with him? I don't know. You're the medicine doc. You figure it out."

To those residents, I want to say that I am now (right now) forgiving you for treating me like shit, but I cannot forgive the disregard you have shown to your patients and the stain you have placed upon the profession of medicine. I was taught that we have a moral obligation to provide the best care for our patients, and I find you lacking.

To all the ER docs out there doing good work and fighting back the tide, thanks. I really do appreciate it, as much as I complain. And it makes me feel fantastic to know that when I send my patients to the ER, they are in good hands.

Choosing a specialty, part 3

So, this will be the last "choosing a specialty" post. I have been asked to render my opinion on emergency medicine, plastics, ortho, and someone couldn't help but pipe up about radiology. These four specialties probably accounted for the career goals of a third of my med school class. I can't stress enough that these are my opinions, and are likely in no way applicable to you.

The most important thing for me to say is that one should not go into ANY profession in medicine with your primary concerns being lifestyle and reimbursement. Those are shitty reasons to do any field of medicine. You should do what you love. You did not go through eight years (minimum) of school plus another three years (minimum) of training to do something that you hate. You'd be a fool.

I remember quite clearly in college I realized that I could actually do anything. It dawned on me that if I put my heart into it, I actually could do anything that I wanted to do with my life: scientist, doctor, engineer, lawyer. That is a privilege that extremely few people have. How dare you waste that privilege doing something just for the money and hours? If you do not want to make use of such a precious opportunity, there are millions of others who would make better use of it. Please, have a better reason for choosing a career than 'shift work.'

People make fun of ortho. Take the smartest and make em the dumbest. FOOBA. Honestly, I'm all right with ortho. I love ortho consults. I get to manage diabetes and high blood pressure, and I don't have to do a discharge summary? Excellent. I couldn't do ortho after I saw one procedure where they were hammering away at a femur. Felt like passing out. I like wood work. Not too crazy about sawing and hammering people.

Plastics is a funny one. Everyone thinks that plastic surgery is all boobs. In reality, the vast majority of plastics is wounds, skin grafts, minor reconstructions, and hands. If you are lucky, you can do some cosmetics, but you're not going to be on Dr. 90210. I still think it's really cool, but there's far more to plastics than making little ones bigger. But I'm no surgeon, so no plastics for me.

Someone mentioned how I knock radiology, which blew my mind. I actually like rads. I wish I could do it, but I needed the patient contact. What kills me about rads is that a lot of my med school colleagues went into rads for easy lifestyle, money, and 9 to 5 hours, and I loved rads far more than them. I was talking Houndsfield units and reviewing criteria for V/Q scans. They couldn't have cared less. And now, they're radiologists? It kills me.

Now, to emergency. I was trying not to comment on emergency medicine, since my opinion of emergency medicine is toxic at best. Keep in mind that my med school class was part of the "ER" tv show boom in emergency medicine interest. I quite clearly remember having ER parties on Thursday nights in college.

I wrote a very long tirade about ER docs, which had nothing to do with my reasons for not choosing emergency medicine, so I have created a separate post for it. I should mention that I do not counsel students at all about ER medicine. I point them as far away from me as possible.

Personally, I had no interest in ER because I liked having continuity of care, and I despise acute care. It was fun, but entirely without satisfaction for me. Also, what I did enjoy about ER was the primary care. Nearly everything I saw in ER was a primary care issue that if they had seen an internist a week before, they could've probably avoided going to the ER. Instead of leg edema, it was decompensated heart failure. Instead of exertional fatigue, it was acute MI. Instead of abscess, it was fasciitis. What ER made me realize is what these people needed wasn't more ER physicians, but they needed a primary care doc.

And so, here I am.

Vets

I am finding it harder and harder to write on this blog, as it is very difficult to write and not give away all kinds of personally identifying information. However, I will take this one moment to say thank you to all of our servicemen and women who have given courageously to this country their time, effort, and even their lives. Without the selfless actions of one American GI, my parents would not be alive, and I would not exist.

And I say this for two reasons. (1) Even though we may see our actions as the most trivial of deeds, they can echo throughout eternity. I saved the life of this woman, and I thought to myself: but for the actions of one soldier over 50 years ago. (2) Whatever your political beliefs, please remember that our soldiers have given greatly to this country, putting themselves in harm's way to protect not only our freedom, but freedom itself. That kind of sacrifice should never be forgotten.

I had a patient the other day who was a WW2 veteran. I asked him about his time in the service, and as he was leaving, I shook his hand and told him, "Thank you for your service to this country." He looked at me a little funny, a little nostalgic. He told me it had been years since anyone had paid him such an honor. That's a shame in my eyes.

Choosing a specialty, part 2

"Hi Ifinding, in a future post, could you briefly describe the negatives that swayed you against other specialties? BTW, I really enjoy your blog. I just discovered it yesterday and can't stop reading it!"

I live to please, so here are some thoughts that swayed me from one specialty to another. Keep in mind that these are thoughts that I had regarding specialties that applied to ME and may not apply to you.

Family medicine: I liked the concept, with regular patients and continuity of care. However, I didn't like taking care of kids, and I didn't like the extreme breadth of disease.

Pediatrics: I don't like taking care of kids. When a 72 yr old diabetic has a heart attack and dies, it's unfortunate, but at least I can console myself and say he had a good run. When a 6 yr old dies, that invariably falls on me. Peds deals with a lot of genetic diseases which are rare, but you can't afford to miss. I hate genetic disorders. Peds has parents. I hate parents.

Psychiatry: while I didn't enjoy adult psych, I really loved child psych. I thought the kids were so precious, and I was absolutely struck by the tragedy of their cases, and how for so many of them, their only fault was being born to shitty parents. However, in the end, I couldn't take the tragic nature of the field.

OB/Gyn: I really liked Gyn. Relatively healthy patients, limited number of interventions, good split between clinic and surgery. I thought it was really neat. The OB part I could've done without, but nothing trumps introducing a mother to her new baby. But so many women didn't want anything to do with me because I was a man, and I wanted to make more lasting connections with my patients.

Surgery: Wow, fun. I really enjoyed the technical nature and the quest for excellence, but the bedside portion was so pitiful. We would do a hemicolectomy for obstruction from metastatic colon cancer, and never talk to the patient about their abysmal prognosis. I didn't want to 'sign off' of a patient who needed help.

Anesthesia: 99% boring, 1% terror. Hate boredom. Hate terror.

Dermatology: I loved derm. L-O-V-E-D. Office procedures, almost entirely outpatient, as much continuity as I wanted, get to see some bizarre and unusual disease mixed in with simple but fulfilling care. If I had the board scores for it, I would've done derm, but I'm just not that smart.

Radiology: Zero direct patient care. No thanks.

Neurology: All diagnosis, no treatment.

Pathology: The most scientific of all specialties, the greatest arbiter of diagnosis, but the only time I get to work with patients is when they're dead. While I loved the science, I wanted to see patients.

So in the end, I went with internal medicine. I loved the diagnostic challenges, the continuity of care, the limited focus compared to family, the treatment aspects, and the attitude. Internists are generally somewhat anal-retentive folks, and a little OCD. We obsess over tests and meds and things like sensitivity and likelihood ratios. There is a constant fight between the art of medicine and the science. In adult care, we are management kings.

But also, we are a dumping ground. We admit patients spurned by every other service: Gyn, neuro, surgery, when everyone else passes, the patient goes to medicine. While I find this aggravating, I also feel that someone has to look out for the patient.

I came to peace with this fact when I talked to a US Marine a while back. I was marveling at his bravery, enlisting in the branch of the services known for being the first to fight. You don't join the marines to avoid war; you join to get your hands dirty. Rather than be proud of his service, he completely downplayed it. "Y'know, when there's a job to do, someone has to step up and say 'I'll do it.'"

And although I'm not in the military, this is pretty much my attitude towards internal medicine. I did not become a doctor to avoid work. I became a doctor because I felt that I could do some good. And whenever people complain that medicine is a dumping ground, my reply is always that there is a patient who needs help, and if no one else will step up, I will. I have even been so bold as to tell other doctors if they don't want to do what's right, then I will.

And when I die, I hope that people won't say what I nice person I was, or that I'll be missed. What I want people to remember about me is that when I was needed, I always answered. I did not become a doctor to rest on my laurels. I came to work.

Choices

When I was finishing up residency, I was working with some medical students. One of the students was absolutely gorgeous. She had this wavy, brunette hair that seemed to flow like water. And she had this scent to her that was so intoxicating. I found myself following her unconsciously, completely entranced by her smell.

She had a crush on me too. Sometimes, I don't know these things. My social skills are poor at best. But with this girl, I knew. Her gaze would linger a little too long. She would look down when I was talking to her, afraid to make eye contact. She kept her head tilted slightly, in that kind of daydreaming pose.

I think about this girl every now and then, and the long string of girls like her whom I have met briefly, and then have left my life. Either I was going or they were, never in those ideal circumstances you see in the movies. And so we meet and we part, with the vague notion that maybe we could've done something, but for the timing.

And I realize now that the problem was never the circumstances or the timing or whatever else. The problem was the choices I've made. When you can appreciate the choices you've made in life, it becomes very difficult to avoid reality. I've made some choices, some of which were terrible. And it became clear to me that as unhappy as I've been, it was from my own hand.

People make fun of the second Matrix movie, but there was an extremely profound line in it. The Oracle tells Neo, "We can never see past the choices we don't understand... you've already made the choice. Now you have to understand it."

When I heard this line in the movie, I thought this was so trite. But looking at my own life, I can see now that my life is composed of the decisions I have already made, and the most anxiety, the most angst is tied behind decisions that I have made and never understood. And as I shed light on them, it becomes clear to me the effects of these choices, and how terrible it truly is that we can't change the decisions we've already made.

Because for the last 15 years of my life, I have chosen everything over love. I was scared of love, and I still am. And it scares me because everything I love leaves me. And gazing with a critical eye, I can see that I have made some remarkably poor choices, in order that I could wake up in the morning and not shoot myself, but exorcising all joy from my life.

Now, understanding the choices I've made is all very enlightening, but it doesn't answer the very simple question: will I choose to love? I don't know. It's one thing to see the gears. It's another thing to be a clocksmith.

Choosing a specialty

Recently, I was talking to a 3rd year student, and he was trying to figure out what to do with his life. He was still a little lost, like most people in their 3rd year. Everything either seems fun or horrible. Everyone expects that moment of, 'This is what I want to do with the rest of my life!' but in reality, few of us get that moment. I can't tell you when I decided on internal medicine. I just did.

I tell most people that they should go with the pathology. Whatever diseases interest you are probably things that will continue to interest you, because the patients can't all be winners. This student told me that he wanted to do ER because he didn't want to see the same thing over and over. I was polite enough not to laugh in his face.

The truth is that every specialty has its bread and butter. For me, that's hypertension and diabetes. For the surgeon, it's gallbladders and appendices. And all specialties have their chronic patients. You can't choose a specialty aiming to avoid these chronic folks or to dodge the routine diseases. The only way to dodge that stuff is to go into a field without direct care: radiology, anesthesia, path...

When I was trying to decide, I posed a simple but profound question to myself: what is my staple diet? Sometimes I get a taste for Mexican, but I can eat rice every day for the rest of my life. And that's what choosing a specialty is like to me. What can I see again and again and always find satisfying? That's the specialty for me.

A new paradigm?

A friend of mine once considered going to officer candidate school (OCS). Of course, he didn't realize this was for folks who want a commission in the armed services, and when we let him know, he reconsidered. However, I don't think that OCS is a bad thing. In fact, I think that things like OCS are quite useful sometimes.

One thing that I think medical school is lacking is training student doctors what it means to be a doctor. There is the education and interviewing and a lot of other aspects that go into medical education. However, I think that a lot of medical schools lack training in the professionalism and ethical behavior of being a doctor. Certainly every school teaches medical ethics, but it is in the safe environment of a classroom. It lacks the thing that OCS excels at: put someone in a real situation and watch them squirm.

An intern I was working with was managing a patient in the clinic, and I saw the patient on a sick visit, and one look at this poor patient was enough to admit him to the hospital. It was a judgment call, but one that the intern should have been able to make. Why didn't the intern admit?

I was the admitting resident and had 3 admissions from the clinic. None of the residents or attendings had contacted me to let me know. Two patients were having acute CHF exacerbations. One was an acute asthma exacerbation. After seeing these three patients, I transferred one on the cardiac stepdown unit, and one patient went to the ICU. Why didn't any of their doctors contact me about the acuity of their patients?

I think that medical school needs to teach doctors to make good decisions, because if you don't want to make good decisions, you shouldn't be a doctor. Being a doctor is all about making decisions. You may not make the right calls all the time, but you must continually question your decision making process, and evaluate yourself critically.

And after confronting all of the medical personnel mentioned above, several mentioned their poor decisions based on workload. They were too busy to do the right thing, and they all recognized that there was a right decision and a wrong one, and that they had not made the right call. But it took being confronted about it. I wasn't mean or rude. After all, in some cases, I was a resident questioning an attending. But if I didn't confront these folks, would they have learned?

I had a part time job once where my boss was a former marine. Let me tell you, having a marine for a boss is a mixed blessing. It turned a pretty easy job into a LOT of work. But the job had relatively little direct supervision. If I did a shitty job, no one would really know. But I always did my best.

My boss recognized me in a meeting, and I was completely stupefied. What had I done other than what was expected? And I realize now that what I had done was something quite simple, but something worth recognition. Without any desire for reward or recognition, with no one looking over my shoulder, I had done my best, because if I was going to do something, then it should be done right.

And I was talking to my boss about being a marine, and he told me that they teach marines something simple but profound. A marine should always do the right thing, even when no one is looking, because that is the best way to judge a man. And I agree. I think that if you can very accurately judge the character of a man by what he does when no one is looking, and by what he does when he is under pressure. Does he do what is right or what is easy?

I told my marine boss that I wanted to be a doctor, and he told me that I would be excellent. What did he know about being a doctor, I thought to myself. He told me that excellence is all about being excellent in all things. And if I can do a good job with essentially meaningless work, then how much better I would be at something where I can make a difference.

And I'll tell you right now, when I see students and residents, I let them know that you can know Robbins word for word, but that won't make you a good doctor. You measure a doctor by how he cares for his patients. And when I was a senior resident, the folks I came down hardest on weren't the ignorant, but on the lazy. I have no sympathy for laziness or arrogance. How can you ever look at yourself in the mirror if you don't do what is right when someone's life is in the balance?

If I could teach that to a medical student, just one, then that would be enough to change the world.

Where's your stethoscope?

Nowadays, the new, hot thing is to wear your stethoscope on a belt clip. The ER folks are in love with this, because they typically don't wear lab coats, and the stethoscope can irritate the neck. Moreover, getting that weight off your neck is very relaxing.

What's interesting is that how a doctor carries a stethoscope can say a lot. The way you wear a stethoscope speaks volumes about when you trained. Here are some observations that I have made.

You carry your stethoscope in a doctor's bag: you remember when penicillin was first mass produced. When someone talks about Osler, your reply is, "Osler was an ass." Your day is done and you are likely dead now.

You wear your stethoscope like a tie (your neck between the ear pieces): You speak of the 'good old days' of fee for service, and bemoan Medicare, as you remember the days when it did not exist. The words, "Evidence Based Medicine" make you want to vomit. Still, you try to impart wisdom to the younger generation of physicians who don't know any better. You reminisce of the days when everyone had traditional indemnity insurance, patients did as they were told, and no one thought medical paternalism was bad.

You wear your stethoscope around your neck: You are a new breed of doctor who trained in the HMO/PPO era. This style is the current norm these days. It is a strain on the neck and if your stethoscope is not long enough, it's quite annoying. However, you comfort yourself with the knowledge that medicine is now guided by science and best evidence, and you wear your stethoscope more for decoration, since you have never heard a murmur in your life, and wouldn't know one if it bit you in the ass.

You use a belt clip or keep your stethoscope in a coat pocket: You are trying to be on the cutting edge, the avant garde of stethoscope fashion. But no one is impressed. And everyone secretly laughs at you when you get your scope caught in the arm of a chair or on a door knob.

Of course, I'm joking around, but really, the generation gaps are there. I think it would be really interesting if people started carrying scopes differently. I am all for keeping it in the pocket. Truth be told, our physical diagnostic skills have gone to the dogs, and I no longer see that the stethoscope deserves a place of prominence around the neck.

And by the way, I ruthlessly stole all these pictures with Google searches. Sorry. However, while googling, I did discover there is a whole world of stethoscope fetishes. Apparently, there are some very creative uses for stethoscopes.

Just wanna be loved

This American Life has once again hit a hot button for me, talking about reactive attachment disorder, which is one of the child psych diagnoses that strikes the most horror in me.

The thing that turned me away from child psych is that it is so absolutely horrible. These kids are absolutely destroyed by forces entirely out of their control. I couldn't deal with child psych because for the most part, the pathology wasn't in the children; it was in the parents. Kids aren't born with reactive attachment disorder. It exists because there are awful people and situations out there, and it is actually possible for a child to grow up without love. The consequences are terrifying.

But one commenter wrote about her own work with foster children, and after listening to the radio program, I got a little hope. Maybe these kids do have a chance. But it takes so much dedication, so much work. And it's hard and scary. I'd like to think I could do it, but I couldn't. My basic pathology is that I desperately want to be loved, not the other way around.

Catharsis: all about being dumped

[This post has nothing to do with medicine. If you have had your fill of self-pity, go ahead and skip this one.]

There have been a lot of comments about the dumping post. I came up with it while driving. I carry a voice recorder with me. My exact quote: "If I ever get into a relationship again, and it goes south, I'm going to dump her before she can dump me. I'm never going to be the dumpee again."

For years, I've lived in a self-imposed emotional isolation, content to say that the risk of loving was far too great, and it was better to be alone. This was a pretty stupid decision, but I certainly can see the reasons behind it. The problem is that rather than take steps forward, I've gone backwards.

If you want to know why I'm so vicious about being dumped, I'll provide you with some context. One episode that jumps to mind was in college. It's classic soap opera. Girl dumps me for my best friend who was seeing her behind my back. It should speak volumes that I blamed myself for this entirely, and rather than get angry, I tried to keep a friendship with them. Part of my motivation was that my entire social circle was tied into these two. I wasn't about to make all my friends pick sides. So, we tried to be friends still. It was almost unavoidable. My friend lived in the same apartment building.

Friday night came, and I waited to hear from the grapevine what plans for the night would be. And I waited, and waited. My roommate was out on a date, so I was in my apartment alone. I sat by the phone for a while, then started calling around. Finally, I went up to my friend's apartment. One of his roommates was there. They had all been there, my friends, and they had hung out for a couple hours, and then left for a bar or club. Due to some circumstances I won't go into, I was physically stuck at home. Even if I wanted to follow them, I couldn't.

The most absurd part of all this was that in order to get to my friend's apartment, you had to walk past mine. So all of my friends had walked right past my apartment to my friend's, and then later walked past again. And at no point in time while I was less than 100 feet away did anyone think to call or even knock as they walked by.

I think what hurt most was I couldn't figure out if it was out of spite over this breakup stuff, or out of sheer apathy, that I mattered so very little that it had not even occurred to them to see if I was in. Despite several phone messages on a variety of answering machines, I never got a call back or an apology. When I confronted them, they said they thought I wasn't in. As if I had somewhere better to be.

I was so angry that I was throwing things all night. Some things are surprisingly sturdy! I am not an overtly angry person. Most of my friends have never seen me angry, but that night, I was furious. And which was the better option: was it better to have friends who were so cruel or so utterly thoughtless?

I made a resolution right then. I would learn to be happy on my own, because it was clear to me that I could not trust other people to be there for me. It took me a while, but I burned those bridges and left all those people behind. And looking back now, I can see what a terrible resolution that was, and how so much of my unhappiness with life was self-inflicted. It was as rash a reaction as possible, but not a surprise. They abandoned me.

Just last month, I realized that my life is governed by an utter fear of abandonment. It scares the crap out of me. I made a list of all the horrors of my life, and when I looked down the page, it was all the same: abandoned by family, by friends, by lovers. And so, that one night in college, more than anything else they had done (and let's see, dumped, two-timed, ridiculed, mocked... the list continues), spelled the end of my friendship with them, because they had done the only thing I couldn't forgive.

And I'm trying now to forgive, and to let go of all the emotional torture I've self-inflicted. And that hurts, but what options do I have? All this time, I have burned with furious indignation. But there is no reward in that. There is no comfort. My anger will not change the past, and very likely has made absolutely no difference whatsoever in the lives of the people who have wronged me. I can keep holding onto my anger, but for what purpose?

And so, I've decided it's time to move on, and that means facing all this fury and quenching it. And at least acknowledging it is a start. And as angry as I seem about this one Friday night, it is only a crumb in a life full of being left behind. And as much as I am trying to grow as a person and move on from all this turbulence, I know in my heart one thing: if given the choice, I would rather be the dumper than the dumpee.

The litmus test for good health care

Once when I was a senior resident, I had an intern who was taking real shitty care of one of his patients. He couldn't have cared less about this patient. His notes were sloppy. His management poor. I was cleaning up all kinds of loose ends. Finally, I confronted him.

He hated the patient. He thought that the patient was manipulative and mean-spirited. To say his care for her was dispassionate would be a compliment compared to the job he was actually doing. But hating a patient doesn't give you the right to do a shit job.

"Yes, she's a bitch, but she is someone's mother. And if you took this kind of care of my mother, I would sue you out of spite. And my mother makes this lady look like Mother Teresa."

There are two tests that are quite useful when caring for patients. It becomes very easy to forget that we are treating people and not diseases, because all we see are the diseases, and it's hard to get to know the people. So it's helpful to ask yourself two questions when you feel a little lost in the storm:

(1) Is this the care I would want for my parents? (2) Would my parents be proud of me if they could see what I'm doing?

If you can answer yes to both questions, then you're doing alright. If not, it's time to take a step back.

Flip flop

When ADOPT came out last year, it was pretty much a home run. Many practitioners were advocating changing guidelines to recommend Avandia (rosiglitazone) as initial monotherapy. I was quite vocal in my disagreement. I think metformin has more favorable effects, blah blah.

Now that rosiglitazone's safety has been seriously questioned, everyone is jumping on the 'TZD's suck' band wagon, which is dragging pioglitazone down with it. I find this very amusing because it kind of typifies the trend in US pharmaceuticals.

I could understand the arguments against Vioxx, a drug made for symptom relief and not much else. Natrecor was disappointing, but it had filled a nonexistent hole anyway. But this Avandia stuff is ridiculous. You can't tell me that optimal glycemic control does not have benefits. We have modeled ALL of glycemic therapy on this idea, that microvascular disease is the consequence of hyperglycemia.

And none of this talk answers a quite serious and obvious question about Avandia. Is Avandia doing something or not doing something? By that I mean is the risk caused by the drug itself or is the increase in heart attacks the same as untreated diabetes? If it's simply the risk of untreated diabetes, well then I'll slap some metformin on top and call it a day. But if the drug is causing heart attacks, that's a different story.

I'm willing to concede cardiovascular disease, but keep in mind that there are a lot of complications of diabetes. Choosing between them is like trading bananas for pears. Is it better to have heart disease or kidney failure? Is it better to be blind or a CHF patient?

I don't like TZD's and I've never been a big fan, but I can't argue with the fact that they work, and work well, and probably are one of the best oral diabetes medications. Since this all came out, I haven't written any scripts, and thankfully I've always preferred pioglitazone so I can at least hedge my bets until we figure out if this is a class effect. But I'd be hard-pressed to say to someone that Avandia was bad for them.

Breaking up

I was listening to This American Life last week, and the episode was about break ups. It was a strange and amusing episode to listen to, and I know that I have felt the same way at times, but it seems like when we talk about break ups, it’s usually the perspective of the dumpee rather than the dumper. It is the dumpee who is all alone, pining for a nonexistent future.

I can certainly sympathize with the dumpee, seeing as that has been my station in life. Being dumped sucks, and after the last time, I have no desire to go through that again. It is all about being hurt, tossed about like in the wake of a passing ship, and while the dumper is getting on with life, the dumpee is stuck in a continual relationship post-game report.

You know, after a football game, the commentators all sit together and break down the game play by play, finding all the faults and mistakes and errors. “In the 2nd quarter, he was far too clingy and came off as desperate. In the playback, you can see he was doing a LOT of hand holding. I think that this is where the momentum turned.” You get the idea. Maybe you even know what I’m talking about. And inevitably, a sick kind of hypothetical game comes up. Maybe if I did this, it would’ve been different. Maybe if I was better about that...

The sick twist to being dumped is that your own self-worth goes in the toilet. Here this person whom you loved and respected has determined you are unlovable, and so that becomes your own self-image, that you actually deserved this, because who could love you? It takes a long time to get back to even keel, and you dream of the day when everything stings a little less.

I for one am sick of this mental torture. I do not want to ever find myself in that place again, full of anguish and self-pity, tortured by the echo of love. I think that if I am in a relationship I see going downhill, next time I will be the dumper. I will be the one to cut my losses, rather than the one left stumbling in the dark.

I am not a mean person, and I don't relish the thought of hurting other people, but it is an issue of self-preservation. A person can only stand so much heartache in a lifetime, and I've had more than enough.

Dear Rhona

I listen to a lot of medical podcasts, in an effort to try to keep pace with the changing medical world. I find that the podcast is the perfect bite-sized piece of information and, with an ipod, can be played just about anywhere while doing just about anything. I listen while I cook or clean, and I've been doing okay except for The Lancet, which is a difficult podcast to follow because of the sheer volume.

But recently, I got a most pleasant surprise: the soft, lilting, Scottish accent of Rhona McDonald, a substitute for the regular Lancet podcaster, Richard Lane. I was actually listening attentively. I have never seen this woman before, and know nothing about her, but I have to admit, I've got a little voice crush.

It reminded me of a girl I knew in college who was a very attractive Chinese girl, but the amazing thing about her was that she had this smart British accent. She grew up in Hong Kong, and spoke proper British English. It's funny how something as silly as an accent can carry so much weight in our minds.

Along the same lines, I had one friend who had such a pleasant, wonderful voice, and whenever she talked to me, I felt all warm and fuzzy. I wanted to have her record my answering machine message. I was so enamored with her, just by her voice, but apparently, since pretty girls are my Kryptonite, I never could manage to say more than 3 words to her at a time, and I haven't seen or heard from her in years. But oh, what a voice.

Practical advice for the new MS1

It's time for the brand new medical students to embark on a long and treacherous path towards being a doctor, and I think of this time as amazing. It is both scary and exciting. It is mysterious but beautiful. It is also one of the first times in your life when you are finally among equals. I thought I might provide a little advice to any MS1's out there on my thoughts about the first year.

On first draft, I wrote about principles and value and being a better human being, and you know what, I don't think you'll need that. You will get it from everyone, and tons has been written about it already. Just google "Advice for new medical students." Instead, I will give some very practical advice.

Unless you have a PhD or were a financial analyst, the first year of med school will be one of the hardest things you've ever done. If you want to do well, you have to ensure that your time is productive.

(1) Figure out how you study best (smarter, not harder). Some need to write it out. Some need to hear it. Some need to read it over and over again. Whatever works best.

(2) If you like to study in the library, you gotta get there early to camp out in a good spot. You have to get a good spot, not only to help you study, but by getting a good spot, your academic cred will go up, and smart people will want to study with you.

(3) Have a study buddy. Not someone you study WITH, but a person you study NEAR. So you can take study breaks together, chit chat. Also, with two people, more chances of getting the good studying spots.

(4) Work hard, play hard. After every test, we'd go to the bar. In med school, that whole waiting till noon thing goes out the window.

(5) Get a study group together. Meet regularly. Our study sessions were great fun, and are some of my best memories from med school.

Enough about studying. Let's talk about life for a minute. You will not have one. So you should take some steps to ensure that your life will not be completely joyless and pathetic.

(6) When you hear about this party or that party, go. Go to every single party. Party hard. Enjoy. You'll need to get all your fun in now, to make up for later.

(7) If you're not studying, you'd better be having fun. First year is all about gas pedal or brake. No neutral.

(8) Have some friends who are just friends, and you don't need to worry about a study session breaking out. I had a group of friends who met every week. It was fantastic fun.

(9) Join a million clubs. It'll help to fill up your non-productive time.

(10) Your med school colleagues will form their entire opinion about you for the next 2 years based on the months of August and September. If you have to be an asshole, don't do it the first two months, huh?

Your expectations of med school have to be a little realistic, and you will find that med school is nothing like any academic activity you've ever done, because it is the best of the best. It's like you've joined the academic equivalent of the Navy SEAL's.

(11) Don't try to show off. No one cares about your MCAT score, because we all know that the MCAT doesn't mean shit anymore. In my class, I was in the top ten for MCAT scores, but I was never again in the top ten for anything throughout the rest of med school. No one cares about the MCAT.

(12) A lot of med schools are pass/fail, but I have heard stories about people not sharing notes or giving out false information to try to game their class rank. This is SO NOT COOL. You will get a reputation for shit like this, and guess what, reputations don't go away so easily any more. Eleven years later, some blogger like me will be writing about how Mousy was such an asshole because she wouldn't let me copy a lecture handout, because she didn't need anything from me, and how much satisfaction I got when she wanted to switch calls with me during 3rd year, and guess what, I didn't need anything from her.

(13) Don't start drama. I have known people who've gotten into fist fights in class, or yelled at a professor. That's just ridiculous. I mean, really.

(14) A lot of schools have a 'med school for dummies' kind of extra study session for students underperforming. Don't make fun of these people. That's just fucking rude. I had to go to one of these sessions. It is already one of the most humiliating things that can happen in med school. Your mockery is not required.

Romance in medical school is possible, and I would encourage you to pursue a love life, but there are some definite pitfalls and caveats to keep in mind.

(15) Med school is a small world, so if you end badly, expect repercussions to follow. And do me a favor. As a guy who was turned down at least twice with the line, "Oh, I'm not going to make the mistake again of dating someone in med school," when you do get into a relationship, don't take out your frustrations with med school out on the other person. Med school is a stressful time, but it's never okay to put other people down to make yourself feel better.

(16) For the guys, most girls in med school are in their early twenties (like you probably are), and are still essentially the same girl who turned you down in college. If you are striking out in the med school world, try the working world. That same 23 yr old girl has developed very different priorities after working for a living. For you ladies, c'mon. Boys never change. We hit our maturity peak at 16. He's not going to grow up and act his age, even if he's going to have MD after his name.

(17) Although most med schools are about 50/50 boy girl now, the number of single men to SINGLE women is still vastly disproportionate. In my class, it was somewhere around 5 to 1. If you like a girl, don't do what I did and wait around. Move quickly, because there are 4 other guys with the same idea.

A little advice for the ladies: dating men in medical school is like car shopping. Do a little research. Figure out what you want from a relationship, what are the deal breakers. Take a test drive. All of med school is your oyster. If you can't find anything good in your class, try one up or one down. However, keep in mind that med school selects against bad boys and heavily favors nice guys. You might want to look outside of med school if dating jerks is your thing.

I have some miscellaneous pieces of advice that don't quite fit into the categories I've set up, but are worth mentioning, because some are extremely practical.

(18) First chance you get, steal a pair of scrubs. If you have access, start wearing scrubs regularly (just not to class). You'll save money on laundry.

(19) Become the 'Go To' guy for something. I had a couple friends who invested in a kegerator. Guess who got invited to every party? Even I had my own 'thing' for med school.

(20) You will be poorer than ever before. Save your pennies. Eat ramen noodles.

(21) Whatever you may think about Drug reps and docs whoring themselves to Big Pharma, the only decent meal you're going to eat for weeks is being provided by the drug rep, free of charge. Swallow your pride and take free food whenever it is offered. You can have standards when you get paid.

That's all I can think of for now (isn't that enough?). I'd be interested to know if anyone else has practical advice for new MS1's.

Death and failure

[SPOILERS ABOUND. BEWARE!]

I was discussing my thoughts on the book "The Spirit Catches You and You Fall Down" with a friend of mine who also read it. We were both amazed at how something so basic as caring for a sick child resulted in such tragic consequences, and it's no surprise to folks like us. We're both Asian, and we've had our own experiences with the clashes of Western medicine and Asian cultures. Neither of us are Hmong though, and it's a pretty different viewpoint.

But then my friend said something really funny to me. "It's so sad that she died, and it was all from—"

"What? Wait a minute. She doesn't die. In fact, according to the book's website, she's still alive."

"No, she died... didn't she?"

"Umm... no she didn't. She's alive."

In medicine, we equate death and failure. We can't separate them, or at least it's very hard. It's why some oncologists will wait till the very last second before sending someone to hospice. It's why we take worse care of DNR patients than full code patients. Even my previous comment is biased towards life-saving measures. Is it worse care, or is it more appropriate care?

But the truth of the matter is that in the medical field, we have a very hard time dealing with death. I have my own theories. I think when it is our own lives, they have a beginning, a middle, and an end, and although most of us are not seeking out death, we understand that it is a part of being human. And we can be content with that based on our own self-worth, which is the totality of our life's experiences.

When you're a doctor, all you see is a part of that life. You may see the beginning. You may just see the middle. But almost never do you see the whole thing. And so a doctor is not able to determine the value of a person's life based on life experiences or anything substantive. We are left with only one way to judge a life's value: quantity. We try to get people as much time as possible, with the belief that adding days will add value.

And in general, board strokes, quantity is valuable, but only to a point. For example, someone on his death bed is probably not concerned with the performance of his stock portfolio. So quantity is clearly not a definitive measure of worth, and so we as doctors are forced to rely on patients and families to tell us what a life is worth, and when it is okay to cut back on quantity, to give a little quality.

I remember one ICU patient was ready to cash out, so I talked to his son, trying to see if we could change to comfort measures. His son was conflicted. "If it was me, I'd say enough is enough. But my dad, he was real stubborn. He would never give up an inch, and I know he would want to fight to the very bitter end. What should I do?"

I could've talked him into palliation, but that's not fair, because in the end, his role isn't to play God, and neither is mine. It's simply to convey his dad's wishes. "When I talk to families, what I really want to know is what the patient would've wanted. Sounds to me like you've given me the answer. I'm gonna keep being real aggressive, and when you think he'd have hit his limit, then you let me know."

Believe it or not, I'm an optimist

I keep getting comment after comment about how discouraging I am, and how I'm all doom and gloom. OMG, please, understand one thing: I LOVE my job. L-O-V-E. Every morning, I look forward to seeing my patients. The whole 'Don't become a doctor' series is about full disclosure. It is the price you pay for being a doctor. Do you really want to read another article on how medicine is difficult, but rewarding?

I got a private comment from a reader asking me if medicine really was so horrible, and I felt a little guilty. So for those of you similarly disheartened, fuck this whole series. I have one question for you: are you in love with medicine, or are you in love with being a doctor? Because I love the medicine. I have gotten into arguments with other docs about whether a patient should be on coumadin or not. You have to be passionate about the medicine. Because you will never be passionate about getting mail addressed DOCTOR ifinding, and you'll feel no sense of fulfillment from the length of your white coat.

So for those of you who are not regular readers of this blog, understand that this blog is written for me and me alone. I do not write this blog for other people. It is my fears and concerns and worries. It is entirely about the things in my life that worry me.

And since I'm getting sooooo many detracting comments, I thought that I might give you a little... treat. Here is a quick list of all the things that make me crazy happy to be a doctor. There are so many wonderful things about being a doctor, and it is a super fantastic job, if you can deal with all the negatives.

(1) There are only a few 'sacred' professions. For example, there are only two people that a family will call to the bedside of a dying person: a priest and a doctor. Caring for the sick and dying, that is a very special kind of duty, and I feel so lucky to have met so many wonderful families, under the absolute worst circumstances, and seen just how beautiful love is. Watching a wedding is a beautiful display of love, but it cannot even come close to watching a woman weeping at her dead husband's bedside. That is sacred. We as physicians are privy to so many of these sacred moments: births, deaths, and everything in between.

(2) There are very few professions where science and humanity mix so intimately. You can be the best scientist in the world, but if you can't interact with people, you'll never be a good clinician. In hard sciences, you have to love the science in a vacuum. In medicine, I love the science because of the difference it makes in people's lives.

(3) Medicine is one of very few professions where you meet people from all walks of life. In medical school, I was rounding and we were talking to a patient who didn't graduate 4th grade. When we came out of the room, the attending told me, "Here we are, over 30 years of higher education cumulatively, and we still need to be in touch and accessible to this guy with a 4th grade education. I tell ya, ifinding, it keeps you humble."

(4) It's very easy to find fulfillment in your work. One of my ICU calls was absolutely miserable, and I was complaining to the nurses why does all this shit happen when I'm on call? I was getting crushed. One of the nurses came up to me and said, "Dr. ifinding, it may seem really bad, but we are so thankful that it is you on call. When I finish my shift, I can sleep easy knowing that you're doing everything you can for my patient. If it was me in that ICU bed, I'd want you by the bedside." In medicine, there is no finer compliment. Whenever I feel lost, I think of all the people I've cared for, and it's easy to find the strength to keep going.

(5) I love puzzles and thought games. Sudoku, crossword puzzles, word jumbles, all kinds of games like that. I love to take chaos and make it into order. That is how I know that I was destined to be an internist. Every patient is like a little puzzle. Do you have diabetes? What are the diagnostic features of pneumocystis pneumonia? Every day, I am mentally challenged. It is exciting.

(6) I like to take care of people. I like having my own patients who think of me as their physician. It is so flattering. I have one patient who hugs me every time she comes in. She is such a sweetheart. But on the opposite end of the spectrum, I have a patient who is a complete asshole, who after years of me killing him with kindness, he's become very cordial and pleasant! The nurses were shocked. All this medicine stuff, it's fun, but without the patients, it would be meaningless to me.

That is what I love about medicine. It lets me take care of people. It lets me do my good for the world one person at a time, and I get the luxury of seeing the fruits of my labor. It is, at its core, remarkably selfish of me, and I am not sure how selfish and selfless can exist in the same action, but that is why I love medicine.

Don't become a doctor #11 - perfection

I was in an elevator one day, and I couldn't help but overhear two neurologists talking (elevator conversations are bad! Even when it's an elevator full of doctors! Don't make me call the HIPAA police!). The only part I caught was one saying, "The PCP really dropped the ball. It was textbook HSV encephalitis."

Just as an aside, herpes simplex virus (either the cold sore or the genital herpes variety) can rarely INFECT YOUR BRAIN, and if you manage to live through that, you'll usually suffer some major neurologic damage.

I was completely stunned at the boldness of the neurologist's statement. But I'm sure that this PCP doesn't need a couple neurologists beating him up. Probably doing a good enough job himself. I know I would.

In medical school, one of my professors told me something wise. "Ifinding, I'll bet you think you should be right 100% of the time, because when you're wrong, people suffer, and maybe die. But guess what? You'll never be right 100% of the time. No one can be. We're human. In fact, you only need to be right 60% of the time. That's what the USMLE says (182 out of 300 on Step 1). I think that the most admirable goal would be 90%. If you can be right 90% of the time, then you'll probably be the best doctor you know. And when you fuck up, then you can say to yourself that you're allowed to be wrong one in ten times."

That's a really easy concept when you're a student, and the only thing at risk are your grades. It's a lot harder when you're trying to decide if it's pericarditis on EKG or an MI. And after a while, you learn painfully that you will be wrong sometimes, and the best you can do is plan for the worst.

So if you can't deal with being wrong sometimes, then stay away from medicine. I long for the days when being wrong meant losing points on my boards. Now when I am wrong, people get hurt, and people die. There aren't many things in medicine that feel worse, but the truth of the matter is that it is unavoidable. No one is 100%. No one.

Don't Become a Doctor

I have been getting a LOT of links lately, and I appreciate the traffic, but I've come to realize that most of the links are for the 'Don't Become a Doctor' series, which I enjoy writing (I am still writing it), but I can see that there probably should be some sort of table of contents or main link page for ease of navigation and for the sake of links.

I just want to be absolutely crystal clear to the new readers out there, as I have gotten a lot of comments and mail about how pessimistic this series is, and how I must hate my job. I LOVE my job. I could write 40 posts on why someone should become a doctor. That's not the point of this series. Because you don't need help coming up with a list of reasons why being a doctor would be great.

To reiterate the purpose of these posts, I think that people spend a lot of time talking about the admirable qualities needed to be a doctor, and the motivations. We talk about the nobility and altruism of medicine, but rarely do we ever talk about the faults and shortcomings. So, I created this series as a guide, so that the eager pre-meds of the world can see the downsides too. And there are good sides, and it can be great, if it is what you want. But if all you are looking for is prestige and money and an easy life, I hope you might reconsider.

But please don't be too disheartened though. If anything I say actually discourages you from being a doctor, post a comment and let me know. I have no right to take your dreams away. I should be accountable for that. And if your dream truly is to be a doctor, I'll be more than happy to give you a litany of reasons why I think medicine is wonderful.

(1) The very worst in people
You only see the very worst of the world. Those are the folks that need our help.

(2) The doctor is OUT
it is very hard to be emotionally available for the people in your life, because you've learned so very well how to suppress it.

(3) There is no cure
We can't cure crap (literally and figuratively)

(4) A cruel mistress
It finds its way into every part of our lives, and continually pulls.

(5) Thou shalt not opine
Your professional opinion is not something to just throw around or wear on your sleeve.

(6) Laughing at the pain of others
What's the alternative? Go home and cry our eyes out every day?

(7) Thankless
All too often, I've taken exceptional care of someone, and been thanked with curses.

(8) Constant change
Some people like fields that are understandable and consistent. Medicine is not such a field.

(9) It's all your fault
Somewhere along the line, we decided as a society that the buck would stop at MD

(10) Hate me
If you want to be a doctor for the prestige and admiration, you're wasting your time.

(11) Perfection
No one is 100%. No one.

(12) Limited Resources
Distributive justice is a harsh reality.

(13) You know too much
You cannot help but assume the worst, because you have seen the worst.

(14) Uncertainty
In medicine, there is uncertainty on all sides.

(15) Guilty
Shouldn't someone be held accountable? And if I'm the patient's doctor, shouldn't it be me?

(16) I've got a secret
Patients have told me things, dark and secret things...

(17) A checkered past
Being a doctor does not come with a clear white coat.

(18) Meaning
the ugly truth is: a job is a job.

(19) Biased
He is still human, and still deserves to be treated like one.

(20) Treating the source
The diseases I am treating are not the principal problems of her life.

(21) Haunted
doctors are always haunted by so many ghosts.

OCD

The medical school admission process selects for people who border on OCD. I would be one of those people. The reason why is because medicine is so damned detail-oriented. It's like putting together Lego's, except you read the instructions once, see it done once, and then you're expected to do it from memory. So having people who are a little neurotic sometimes helps.

And sure enough, when I'm doing my thing, I've got it down to a T. I'm ordering 5,000 labs, getting x-rays, quizzing students on the diagnostic criteria for hemochromatosis. Beware my Doctor Fu. I'll check back on things, and I'll hear, "Oh that Dr. ifinding is so thorough!" But where this spills over into my personal life can be a little annoying.

I can never remember if I locked my car. I will go back from my office or from the hospital to check and make sure I locked my car. Even now, just talking about it, I want to go and check. Even worse, my front door. I am always so glad when I have a place where the door automatically locks.

I am always worried that I left my burners going on my range, or left the toaster oven on. Every day before I leave, I have to check both to make sure they're off. This might even sound somewhat reasonable till I tell you that I've been doing this daily, but I wasn't cooking for about 2 weeks. That's right, I was checking burners that I hadn't used in 2 weeks.

I have a pathologic fear someone is trying to page me and I'll miss it. Weekends, at night, my pager is always on. It's really, really hard for me to turn it off. I'm even worse with my cell phone.

And I can't pack like a normal person. I was gone for a weekend, and when I finished packing for the trip, I had 5 days of clothing packed for a 2 days. I had packed sweaters, jeans, boots, and a jacket for 90 degree weather.

I need help.

Systems based care

A while ago, I attended a social event with some of the support staff. I was actually quite surprised to be invited. After all, the staff and the physicians sometimes don't get along so well, and so there's can be a little tension. We talked quite a bit about the different residents and doctors, and it got me thinking about multidisciplinary care, and how sometimes we judge each other on everything but medical ability.

My mom is a nurse, so she always told me that I have to be nice to the staff, and I should always be on my best behavior, and never mean or rude. She would always remind me of my pediatrician growing up, who was a saint of a man.

So I've always tried to be on my best behavior with the nurses and staff, because they are not paid to put up with attitude from me. And I believe that people who like you will help you. Case and point, when I was rounding in the hospital as a resident, one of the interns was presenting, "The patient hasn't had a bowel movement in 2 days and—"

"Wait a minute," I broke in. "Tracy told me that he had a BM yesterday evening, and now he's got diarrhea! I asked her to send a sample." Sure enough, we walk in the room and there is that wonderful smell of melena. The intern asked me after rounds how I knew the patients so well. "The nurse spends all day with the patient. You should try talking to them."

Anyway, back to my original point, whenever I hear nurses complain about doctors, I'm always surprised, because it is often things that the doctor didn't even realize that have earned him such scorn. There's an asshole surgeon who walks around with a coffee all the time the nurses would mock him and his coffee cup behind his back. When I talked to him one day, he thought that he was beloved.

One social worker thanked me profusely for meeting with a family, because another resident was supposed to do it but was called away. Why was she glad it was me? Because the other resident comes from a culture where you don't make a lot of solid eye contact, so he doesn't look patients or family in the eye. And everyone thinks he's pathologically shy or else trying to hide something.

I have seen excellent physicians hated, and incompetent physicians loved by staff, as well as the converse: I've seen great nurses despised and horrible nurses loved by doctors. It took me a while to realize that our ability to interact productively with other health professionals is a skill in and of itself, and multidisciplinary care isn't something you can just assume (so much so that systems based care is part of all residency curricula). So for my part, I try always to be polite and cheerful, and only to be critical where it's appropriate.

And sometimes, when I'm not sure, I'll call my mom. One time, a nurse called me with a low BP of 87/53 (so obviously a machine value, since people almost always report even numbers or multiples of five), so I asked if she rechecked it. She acted like I asked her to part the Red Sea. "Why don't you get up here and recheck it?"

When I got home, I called my mom and asked her, "This nurse called me with a low BP on a patient, and so I asked her if she rechecked it but—"

"—and she didn't recheck it, right? Well, I'll bet she didn't check it the first time either. The tech probably did. She probably didn't do a manual either. That's just plain lazy." I love my mom.

Truer words

Hmong in California by yankeepez

I have been reading "The Spirit Catches You and You Fall Down" which is a book about Lia Lee, a Hmong infant with a terrible seizure disorder, and the culture clash between the American medical system and the Hmong people. I am instantly wary of all such books, because 99% of them are about how stupid the American medical system is, and lay the blame squarely at the doctors' feet.

This book is remarkably fair, and showcases the completely divergent cultural attitudes. I was discussing this book with a colleague, and remarked, "This story is horrible. I almost wish it was malpractice, but how much worse when everyone has the best of intentions, and still they cannot do something so basic as care for a little girl."

There are two things about this book that got to me though. One is that the book talks greatly about the Hmong people. It helped me to understand a lot about the Hmong patients I have seen, but the thing that got me the most is how the author talks about Hmong culture, but in reality, I have discovered something on my own quite in opposition to the book.

The problem with immigrant cultures in the US is not just one of assimilation. It is that the culture of the Old World is stagnant. It cannot grow. All change is viewed as corruption from the American way of life, and these transplants who were once the most liberal of their generation become the most rigidly conservative. And for me, the way of life that I was taught I now understand to be archaic. I am a man living a dead culture.

The other bit from the book is a line from one of the Hmong people, Jonas Vangay, a French educated man who helps the Hmong community to navigate the American bureaucracy. He utters this aphorism: "I am always the one who laughs last at a joke. I am a chameleon animal. You can place me anyplace, and I will survive, but I will not belong [sic]. I must tell you that I do not really belong anywhere."

I have never read a line that I have felt is a more appropriate description for myself. And I can't help but think to myself that truer words have never been spoken.

Worth its weight

While I was going through my safety deposit box, I looked through all the gold I have. It's not much (please don't rob me): a few coins, some jewelry. It's all 24 karat. The reason why is because all my gold comes from my parents. Now, a lot of Asians are obsessed with 24k gold, but my parents are war survivors.

For those of you without Asian parents, gold comes in a variety of purities. 24k gold is the most pure gold available. My parents have never bought anything 14k, with the explanation that it is worthless, fake. And to understand why, you should understand that my parents lived through war. My friends talk about their parents growing up in post-war America, in suburbs or on farms. My parents grew up in a war zone. My parents' stories of their youth involve starving and refugee camps and bombs and explosions.

And so my parents have an acute awareness of the value of things. Paper money is only paper. Credit cards are just plastic. Banks are only buildings. But a can of spam can feed a family for a week, and gold is always valuable. No matter where you are in the world, no matter what the circumstances, someone always is willing to trade for gold.

And it seems strange to me that other people don't grow up with this kind of wisdom. Sometimes, I wonder how much of what I do is influenced by tidbits of knowledge like this.

Safety deposit box

Vault I by chesh2000pro

Now that I have a J-O-B, and I am officially an adult, I decided to get a safety deposit box to store all those invaluables, like some jewelry and papers.

I went to the bank and signed up for a box. The bank teller and I went into the vault, and we both put our keys into the locks, and I pulled out the box. The teller escorted me to a private room, and I played with the contents, putting this in and taking this out.

And driving away from the bank, I thought it was so funny how much trouble it was: the vault, the locks, the security, the private room. We spend so much time and trouble to guard and protect things. Everything in my safety deposit box, it can't be worth more than a few thousand dollars.

Yet we are so utterly careless with our emotions. We hurt each other so recklessly without a passing thought. We guard things that can be replaced, but we don't protect the things that really matter.

And sometimes, I can see why, because if we could lock our hearts in little steel boxes, then how could we ever give our hearts to each other, share our joys and sorrows? I'm learning, slowly, that I have long locked away my heart, and I have kept it safe, but how can I share my heart if it's hidden away?

Worth a bag of moon sapphires

So, unless you were living under a rock, you know about LiveEarth, which for you under-rock dwellers is a concert to help promote the cause of preventing climate change. There were a few things offered as simple things you can do to reduce your carbon footprint. These suggestions were (1) changing to fluorescent lightbulbs, (2) using energy efficient appliances, (3) turning off lights and unplugging things when not in use, (4) carpooling or using public transport. Gosh, that looks familiar, doesn't it?

I have to admit, I like Al Gore now. I wasn't a big fan of him when he was running for president, but he's managed to pull a Jimmy Carter, and make a bigger name for himself after politics than he ever did in Washington. I'm pretty impressed, and seeing as we're on the same page about a lot of this environment stuff, he's okay in my book. He has ridden the mighty moon worm, after all.

You're probably wondering what's up with me. Graduated residency. Got a job. Moved. Still in the Midwest. That's pretty much it for personal details.

At arm's length

In medical school, I remember quite distinctly the day we talked about personality disorders. We discussed schizoid personality disorder. These are the folks who prefer solitude. They are lighthouse keepers or wander the desert. This is in stark contrast to social anxiety disorder, where a person is unable to interact with people, and this inability causes great distress.

I remember this because it was when I realized that I have made some terrible decisions in my life, choices that I am not proud of, in order to wake up in the morning and not shoot myself.

I was recently forced to do a lot of introspection. This is something that I am relatively comfortable with. I keep this blog, I write in a journal, I feel like I am pretty in touch. But surprisingly, putting a voice to my inner monologue was quite horrifying.

In my life, I've had my fair share of romantic disappointments and failures. Couple this with other issues with intimacy and relationships growing up, and somewhere along the line, I decided that I could not take it anymore. I made the quite conscious decision to hold the world at arm's length, to distance myself emotionally from all this turbulence. And without that horror, I've thrived. I've done well in medical school and residency, and I feel like I've managed to accomplish quite a bit in my life.

But it comes at a steep price. Sure enough, I have not had my heart broken in a long time, and I haven't felt that pain again, but the problem is that the pain and joy come from the same place. I have cut myself off from a world of happiness, because the risk of pain was unacceptable.

And I've watched life pass me by from my little castle, with all interlopers thwarted by the high walls and deep moat. And actually, if I am really honest about it, women have tried, some trying pretty hard, to get inside. And rather than welcome them in, I have put up more walls, and closed myself off.

This distance has its pluses. I can unflinchingly deal with most patient interactions. I've had people cry, people yell at me, the whole gamut of emotions, and I have been able to be empathic, and none of it hurts me, because I don't let them get close. They have to work on my schedule. I can deal with patients in convenient 15-20 minute chunks. They open their doors to me, but it isn't reciprocal.

It's too bad that joy and sorrow come from the same place, and that it is our greatest loves who can hurt us the most. I just don't know if I can risk it. I don't know if my heart can take it. I so desperately want to be loved, but the thought of me loving another person is absolutely petrifying.

I portray to the rest of the world a man of confidence, an outgoing and gregarious guy, but at heart, I am none of those things. They are adaptations so that I can operate in this extroverted world. And I think of how wonderful it would be to meet a girl who could cut through all of this façade and get to know the real me, and not this face that I portray to the world. She would tell me, "Hey, it's okay. This is safe, you and me," and I could finally, finally let my guard down.

No touching

Kilmer Middle School bans handshakes, high fives, hugs.

So, I happened to flip past CNN and Paula Zahn was having a talking head bit about Kilmer Middle School and their policy of no handshakes, no high fives, no hugs, no touching essentially. People are arguing back and forth, and there are all sorts of positions one way or the other.

Rationally, I can understand both arguments. However, in my gut, I found this rule to be outrageous. I went to a private school, and we were reprimanded for NOT shaking hands. Hugs I can understand, but the handshake? The handshake is the most basic unit of human, adult interaction. You might as well ban smiling or saying hello.

These days, the only human interaction I have is shaking hands. If I didn't have that, I might as well be a hermit.

Completely disarmed

A friend of mine made me blush the other day, which isn't much of an accomplishment, but it made me think a little. I started to tell this story, but thought better of it. But now, I find myself wanting to tell this story. I'm not trying to add suspense. It's actually a terrible story. Anecdote is a better word.

I had a patient not too long ago who was completely gorgeous. She was radiant and beautiful, and it was ridiculous that I would be put in charge of her care. I actively avoided entering the room. She had some problems, and eventually it was far over the intern's head, so it was up to me. It took a while to get things straightened out, but after nearly a week, I still had a hard time looking her in the eyes.

The only point to this story is that this woman could've absolutely had her way with me. If she had told me to give her 4 kilos of Oxycontin, I'd have written the script then and there.

And that was part of why I was avoiding her room. I know my weaknesses, and pretty girls are my kryptonite. I get all nervous and apprehensive. I look down a lot. I am for all intents and purposes quite useless. So I've done some hard work to try to desensitize myself. I made a point to talk to all the pretty nurses in the hospital. I try to smile and be friendly. But still, every now and then, I find myself completely disarmed.

31 flavors and then some

Interns come in so many different flavors, and it can be hard to be a senior resident. Being a senior is a unique skill, and so I hope that I can provide a little guidance.

1. the stupid — his fund of knowledge is bankrupt.
   
2. the slacker — rounding on time? Not this guy.
   
3. the cluttered — Most labcoats have 5 pockets. This 'tern needs more.
   
4. the superstar — what I told one of my superstar 'terns: "I love having you on service. I get to eat a nice long breakfast."
   
5. the casual — He is completely frustrating in his unflappability. You'd swear he smokes pot.
   
6. the procedurist — He is single-minded in his focus to do every humanly possible procedure. But H+P? Pass.
   
7. the overwhelmed — One of my interns spent 4 hours doing an H+P. Think about that. FOUR HOURS.
   
8. the workaholic — His solution to all problems is work harder. While admirable, not always the best policy.
   
9. the earnest — "Well, I didn't document a skin exam because I didn't look at all of his skin, just his head, neck, chest, admonen, and legs." An actual quote.
   
10. the overconfident — He does not know what he does not know.
    
11. the disrespectful — I had one intern who was so disrespectful that I actually told him, "What makes you think you know anything?" I am not above putting a disrespectful intern in his place.
    
12. the unprofessional — All the above, while quirky, are just aspects of all of our personalities. At some point in time, we were all one of these flavors of intern. But without fail, the most dangerous intern is the unprofessional one. From a core competencies standpoint, knowledge can be taught, systems can be navigated, practice based learning speaks for itself, communication can be instructed, but you can't teach how to be professional. One of my attendings said something profound on the matter: "Ifinding, tell me, how do you teach someone that lying is wrong? I don't have a fix for that."

It may sound like I'm hating on the interns, but the truth of the matter is this: if you are an intern, there are only two things that any senior resident are looking for. He wants you to (1) work hard and (2) give a damn. Everything else can be taught. And my favorite interns aren't the smartest or most talented, but the ones who I called at 4AM and still got the job done.

I'm sure that I'm forgetting about some flavors of interns. Feel free to leave a comment with your favorite flavor of intern.

Delightfully tacky

behind the scenes at hooters by o0karen0o

I know this probably won't endear me to the female readers, but I love Hooters. I would say that I really like the food, but I can hear the outcry already. The food is very good though, and it's hard to get spicy hot American food, but their wings and sauce are HOT.

But the best part about Hooters is that it revels in its tackiness. This is what drew me to Hooters on a beautiful day with a friend of mine, Macintosh. Mac had never been to Hooters before, so we had to go. Our server girl was nice. It's just a fun place to eat.

I actually go by myself sometimes because the Hooters near me has an outdoor patio where few people sit (because indoors are where all the girls are), so if I want to eat outside, there's always a table. It helps that I actually like the food.

My favorite Hooters memory was in med school. Me and Chocolate Thunder went on one of our man dates. We went to the local museum and soaked up the arts. Afterwards, we had to counterbalance all that culture, so we stopped at Hooters for dinner! The waitress thought that was hilarious. I mean, how many people at Hooters just spent a day at the museum?

The confusing thing to me was the table next to us was some guy with his 4 yr old girl and his 60's mother. Overhearing their conversation, he took his mother to Hooters for her birthday. WTF? That just doesn't make much sense. I mean, who takes his mother AND his daughter to Hooters?

If you've never been, I recommend it, because it's one of those places where you feel like they enjoy your presence, and sometimes when you live a solitary life, it's very nice to have someone talk to you for a minute and seem interested. ... I must really be starved for meaningful human contact.

Why I can never vote Republican ever again

I was watching Fox News this morning, and they were talking about racial profiling for terrorists. One of the interviewees was advocating profiling Muslims to improve the yield of security measures. For a while, it was a very reasonable discussion. Arguments about slippery slopes and non-Arabic Muslims, echoing of Manzanar and Japanese internment camps, versus efficiency and efficacy of our current national security model.

Then, one of the interviewees said by far the dumbest thing anyone has ever said in the history of the spoken word, since caveman first grunted to another caveman. I'm paraphrasing: Look at Israel. They are surrounded by Muslim nations, and they have used profiling very successfully to manage threats to their security. They should be our model for how to deal with terrorism.

So, here are as many problems with that statement as I can come up with in 10 minutes: (1) Israel still has terrorist attacks on a nearly daily basis. (2) Profiling is easy when you profile everyone. They are SURROUNDED by Muslims. It's not like they're picking a couple people out. (3) You can't profile the fastest growing religion in the world. Indonesia is the largest Muslim country in the world. There have been Filipino Islamic terrorists for decades. And what about Chechnya? They're fucking WHITE. How are you gonna profile WHITE? (4) Do we really want to use Israel as a model for Middle East relations? Really? Because they get along with their neighbors sooooo well. (5) Profiling will only enrage more people. Has profiling blacks done anything except piss off a lot of black people? I guess it also makes white people feel better. (6) Israel is a model for terrible security decisions. They continually aggravate and irritate, rather than try to address the root causes of terrorism.

Okay, that's all I can do in ten minutes. I really should learn to keep flipping past Fox News.

The Talk

I’ve given ‘the Talk’ more times than I can count. I’ve gotten quite good at it, and I’m very comfortable doing it. But whenever I have the chance to see someone else give the talk, I listen in to pick up things that I can use, or else see things that I would not use. On my last ICU rotation, I had the chance to sit in on a few talks, given by a variety of services.

One thing that I realized very quickly is that everyone has a bias when they give the talk. My bias is in favor of palliative care and hospice services. To me, a 5% chance of survival is a death sentence, but to a lot of people, that’s more than a fighting chance. We all take something different into the room with us when we talk to family.

Watching other attendings give the talk, there were a lot of things I wouldn’t do. None of this stuff is wrong per se, it’s just stuff that I wouldn’t do. My goal is to simplify a complicated situation. One of my attendings complimented me by saying, “You’ve got a remarkable ability to boil a complicated situation down into bite sized portions without losing sight of the person.” That was high praise in my book.

And so what I try to do is to make something complicated and fraught with emotional turmoil into something easy to digest. That doesn’t mean it’s palatable, but it can be grasped and understood.

I saw was one doc who tried to connect emotionally with the family. It was all hands-on and happy to meet you. He shook hands and hugged and patted shoulders and referred to everyone affectionately: mom and dad this, bro and sis that. He asked everyone their own opinion and encouraged everyone to talk.

The next day, the patient worsened, and I asked the family to meet again for an update, and they asked not to meet with that attending again. They saw through him like a window. They knew his concern wasn't genuine. Not that he was trying to be malicious or fake, but if you're going to play the sympathy card, you have to actually sympathize. This is why empathy is much more powerful. After you have practiced for a while, empathy is much easier. As a reminder: sympathy = I feel sorry for you. Empathy = I can see why you'd be sad. Sympathy is emotion. Empathy is thinking.

Another doc was very in tune with palliative care and hospice, but the way he presented it made it so unpalatable. He was a former collegiate athlete, so everything was a sports metaphor. It was all 'we're not going to win,' and 'do you want to throw in the towel?' Well, NO ONE wants to lose. It's like what Herm Edwards (the former NY Jets head coach) said: "You play to win the game. Hello? You play to win the game. You don't play it to just play it."

It's not fair to equate palliative care with losing, because truthfully, it's not. Palliative care is all about changing what it means to win. It's recognizing that winning isn't always about living long, but also about living well. And that choice isn't quitting and it isn't losing and it isn't giving up. A family shouldn't feel guilty for making a choice like this.

A lot of docs recommend being 'in touch' with the family, crying with them, holding hands and dabbing at tears, mourning with the family, blah blah blah. This is a mistake. It has its role, for sure, but when you are treating a patient, families are looking for authority. Like when you meet a police detective, you want him to say, "Hey, we're going to do our best to catch this guy. You let me worry about it." You don't want him to say, "I can feel your pain. Let's have a good cry, and you can tell me some stories about how he liked to fish." You want your doctor to be confident.

And it's not all about confidence in prognosis, but confident is about attitude. I may not know how things will turn out, but I am prepared for the outcome. I want families to go home at night thinking, "Well, I don't know how this will turn out, but my loved one is in good hands. I can sleep tonight and worry tomorrow."