I am the job

This year, I had the chance to take Christmas off, and I was happy to take a nice long weekend, but I find that I can't stop thinking about patient care items. One of the strange things about being on vacation is that it's not so much a vacation from a location as much as it is a vacation from the profession. No more decisions, I just want to relax. But I realize now that I've done something quite dangerous: I have become the job.

Even in my regular life, it shows. I don't do much outside the medical world. I eat out sometimes. I go to coffee shops. But most of my time is spent simply waiting to get back to being a doctor. Outside of the white coat, I'm not sure who I am.

So, I need to find myself a little and start enjoying life, now that I've got some time to do just that. But how do you go about getting a life? I'm really not sure. If it takes more effort than going to Starbucks, I might be in trouble.

Every now and then...

I think one of the things that I feared the most about being a doctor was crying. I was very afraid that my patients would cry. I myself am a pretty emotional guy, and I would probably cry too, so I was eager to keep an emotional distance. But one attending I worked with bucked that notion. Why shouldn't I cry? Am I made of stone? Compassion is a noble thing, not to be hidden or suppressed.

And since then, I have tried to be compassionate to the emotional wellbeing of my patients. Call it biopsychosocial if you like. I try to make sure my patients know that it is my job to care for them, not their disease. And most of the time, this is okay, but every now and then, it can be tough.

I had one patient, a very nice lady with fibromyalgia and IBS. I know the data as well as anyone else. Chances are she has a background of abuse or other psychological trauma. But I'm patient and I wait for her to feel comfortable with me. After several months, it comes out one afternoon. She had recently been mugged, and it gave her flashbacks to when she was a little girl, and she was physically and sexually abused by her father. I don't know about you, but it's hard to sit in a room with a woman who is telling you her deepest secrets of being abused and raped and not shed a tear.

We sat in the office crying, both of us, and it was tough, but every now and then, it is good to be reminded that there is more to patient care than titration of meds and diagnostic testing: that seeing her that day and letting her share the deepest secret of her life probably did her more good than all the meds I'd written.

Don't Become a Doctor #13 - You know too much

There's a phrase in medicine: zebra hunting. When you hear the beating of hooves, think horses, not zebras. What this means is that common things occur commonly, and so when presented with a set of symptoms, look for the common disease first. Even an uncommon presentation of a common problem is more likely than a common presentation of an uncommon problem. If you go looking for the unlikely instead of the obvious, you are hunting zebras.

And that's all well and good until it's your own friends and family. With patients, you can play the odds, calculate the risk, give people choices. With family, you cannot help but assume the worst, because you have seen the worst. It's never a simple cold: it's pneumonia. It's never a headache: it's an intracranial hemorrhage.

You have seen too much. You have been exposed to the worst case scenario on a daily basis. You have seen breast cancer fungate. You have seen ischemic bowel. You have seen everything wrong that can happen to the human body, and the slightest hint of such a fate sets off all sorts of alarms. It is too great a risk to hope for the best.

Having all the knowledge and trying to use it on loved ones, it is paralyzing. It is an exercise in fear. It is reading NTSB safety reports while on a plane flying through turbulence. You can only see the worst possible outcome. And that is part of what it is to be a doctor.

Continuity of care

I saw a patient whom I had seen 2 years ago. At that time, I told her it was either one of two things. I gave her some scripts and told her to follow up with her primary care doctor for further workup. After 2 years, she came back with the exact same problem, but in the intervening two years, she has seen 4 internists, 3 urgent cares, 2 ER visits, and 2 specialists all for the same problem, and never her primary care doc. I was foolish enough to order records, and I wanted to cry. Every assessment is the same: this is either diagnoses A or diagnosis B. Follow up with PCP.

I had another patient a while back who was on her 6th internist in 6 years. Every internist and every specialist told her the same thing every time, but she only saw each doctor once. Which is no surprise whatsoever. Because we all saw the same things.

Some people think that the more doctors you see, the better. This is, by and large, false. As doctors, we're trained to think of common things first, and so when presented with a certain set of symptoms and findings, we look for the common disease. If you took a room full of doctors and gave us all a set of symptoms, 80% of us will come up with the same diagnosis, regardless of experience or training. Because we find the common one first.

It's like only being able to read the first page of a book. There may be so much more there, but if all you have is one page, what can you possibly know?

Immunized

I got my flu shot last week, and I am feeling MISERABLE. Usually I am entirely unfazed by vaccinations, but I am ready to collapse from exhaustion. As well, my shoulder is screaming sore. Still, when people ask me if it was 'worth it' to get the immunization, I say yes, because anyone who has to ask has never had the Flu before.

Someone told me the other day that he didn't want a flu shot because he didn't trust the mercury content. WTF? Are people STILL talking about thimerasol?

oops

I have to apologize. I accidentally clicked to reject all recent comments instead of approve. So to those of you who commented, my apologies.

Brought to you by Ambien

Lately, I can't sleep. I do my work. I come home. I'm exhausted some days. I eat dinner. I watch TV. I play around on the internets. I go to bed. And I lie in bed for 2 hours. It is utterly frustrating.

I know all about sleep hygiene. I have given this talk a ridiculous number of times. It is advice so trite that most of my patients thumb through a magazine while I give the talk. You've undoubtedly heard it before: set a fixed bedtime and waking time, don't nap, avoid caffeine and alcohol, exercise regularly...

Most of the time I am giving advice to patients, I am being hypocritical, but except for the caffeine part, I actually follow this sleep hygiene stuff, and still! Insomnia! It is utterly frustrating and agonizing. It seems like there should be some way to sleep better, some way that I can relax and get a good night of sleep every time. I wish I knew how.

Don't Become a Doctor #12 - Limited resources

One of the main principles of medical ethics is something called distributive justice. What it means is that resources should be allocated as fairly as possible, and when resources are limited, they should be aimed towards bringing the greatest benefit for all, not some.

When students think about distributive justice, they often call to mind health care expenditures and waiting lists for specialists. They think of MRI's and other expensive tests. It is a little detached, but the truth is that distributive justice is a harsh reality in medical care.

The easiest example is mass casualty situations. The first rule of triage is treat who you can save. If you can't save them, then don't waste your resources. It's cold, but it's society's competing interest.

But you don't have to have a mass casualty to find limitations in resources. I have been in a lot of tough situations as a resident. I've had a full ICU and patients needing a unit bed. I've had simultaneous codes. I've had three patients all go into respiratory failure at the same time. There are a lot of tough choices to be made there.

Now, most non-medical folks cringe to hear things like that. 'We need more nurses' or more financial support, or more beds, or whatever else. They mean well, but they miss the point. There will always be limits, but the most precious resource isn't any of those things. As a physician, I am the limited resource. My attention is a valuable commodity, and how I allocate it can be the difference in who lives and who dies. That is a tough call to make, and if you want to be a doctor, it's a call you'll have to make.

Heart

Some days, I worry that I don't have enough heart to do medicine. I worry that I don't have enough compassion for it. I worry that it will burn me out, and I'll find myself resenting my patients and wishing they'd stop bothering me. Everyone looks to the doctor for the answers, and I don't have any answers. I don't have any cures. I can't fix things. I worry.

Compassion isn't something that comes easily. It takes work to try to understand someone's point of view. It takes a lot of energy to see someone else's perspective. It is hard to show understanding in the face of something that you can't understand.

I wish that I had all the answers. I wish that it came easily. But some days, it's a lot of effort just to phone it in. Medicine is hard work. I can see why so many new students are looking to fields like radiology where you never meet your patients. Because there is something very attractive to never getting to know your patients. It would be nice not to become entangled in their lives, and sit up at night wondering if cancer got the better of Mr P, or what I can do to convince Mrs C just to eat. I am paid to care about these things, but a person can only care so much.

Let's shit on the interns

July in the hospital means one thing: new interns. It's common knowledge that going to the hospital in July is risky business. I know the new interns are here because I can hear the staff complaining. Every third sentence starts, 'Those dumb interns... *sigh*!' To everyone out there bitching about the interns' growing pains, I'd like to say this: STFU!

When I was a new intern, I caught flack from everyone: my attending, my senior, RN's, PCT's, MA's, RT's, EMT's, PT's, OT's, case managers, and even some custodial staff (strangely enough, I never heard a bad word from social work or nutrition...). I discovered one universal truth to being an intern in July: no one has your back.

My intern hell continued until my ICU month. Nurse Battle Axe was taking care of one of my patients. BA had been doing critical care since I was in diapers. The amount of critical care knowledge she would lose in a particularly violent sneeze was still more than I knew. So, when she asked me a question, I assumed it was rhetorical.

"I asked, 'What do you want to do, doctor?'" she repeated. My patient had a blood pressure of 70/30 despite aggressive hydration. I had no clue what to do. So, I sat down and thought about it, and after a little soul searching, I decided to start a pressor.

"Um, can we start dopamine? ... please?"

"Sure, doc!" she replied, and walked into the room, pushed a button on an IV pump, and dopamine was in. BP improved to 90/60. Mission accomplished.

Later, I thought about it, and she must've had the dopamine hung already and the line primed. But she let me make the call. I asked her about it, and she told me, "Dr. ifinding, you know I've always got your back!"

Part of being an intern is painful, and that's just how it is, but it certainly doesn't have to be more painful than it already is. So take it easy on the interns, huh? Or at least don't badmouth them to their face.

This has nothing to do with medicine at all

I am so disappointed that Petrozza lost on "Hell's Kitchen" tonight! I thought it was not right. He was a real gentleman and after the first few episodes, never had a bad service, whereas Christina continually had bad services right up to the end! And Christina's menu was so unimpressive! Sliders? OMFG, I'm not going to a Gordon Ramsay restaurant for mini hamburgers! Not unless it's a black truffle with fois gras hamburger.

But the thing that really got me was the comment at the end by chef Ramsay when he said that Christina had more potential and time, as she was significantly younger. Well, fuck, if you were going to choose Christina anyway, then why bother? Might as well just cut Petrozza a check and let him go home with some dignity. I mean, Christina had food sent back, which alone was enough for previous contestants to lose.

I think ultimately, looking at their menus, Christina's menu did not have much imagination, and really did not excite me whatsoever. Ramsay's restaurants average $100+ for a three course meal. For that price, the food not only has to be excellent, but imaginative. I got a lot more excited by Petrozza's menu, and would be much more likely to eat off of his menu.

It just seems to me more fuel for the 'nice guys finish last' fire. If I was a chef, I wouldn't work for Christina. It would be like having an intern run the medicine service. Personally, I love when I get a seasoned intern on service.

Humble Pie

I think that I'll try to post on a monthly basis. I know, I know, once a MONTH? But right now, that's as fast as I can go! And by the way, I'm taking down my old archives 2002-2004. Sorry! Maybe I'll put up some selected posts as a 'best of' kinda thing?

Every step in the medical education process is a humbling one. There's never a safe moment when medicine won't put you in your place. For me, the most humbling part of my medical education was the application process. I was waitlisted to some, rejected by most. My applicant year was extremely competitive, and some of my rejection letters acknowledged that in other years I would've been accepted, but for circumstance.

I lived in fear of my mailbox. I made a large pile of rejection letters on my desk. I was going to burn them once I got accepted, but after several months, my burning plan was lost in self-pity. Two schools were kind enough to reject me via postcard. I that that was the biggest slap in the face, that my rejection was not worth an envelope.

The interviews were even worse. One interviewer actually told me that I had no business applying to med school, and I shouldn't bother to pursue it any further. Another interview, I forgot my tie of all things. The interviewer took one look at me and didn't bother to listen to a word I said.

So, in early June while I was packing up my apartment and getting ready to move back home, I got an overnight express letter: 'Congratulations! Blah, blah, blah. Sign here!' One of my waitlist schools came through.

Now that I'm further along, it's easy to look back on those times with nostalgia, but it's awfully humbling to know that the only reason I got into medical school was because someone higher up on the list said 'No thanks, I can do better.' Thanks, dude. I really didn't want to move in with my mom.

A laugh

This post is one of the pre-written posts I mentioned earlier. I've been sitting on it for a couple months, trying to tune it up, but at this point, I give up.

Sometimes, laughter is good medicine. Sometimes, when faced with horrible situations, the only way to deal is to throw up your hands and chuckle.

One month on ICU, I had nothing but nightmare calls. My first call I had four patients code in a row, nearly back to back, and all four expired: four emergencies, four families destroyed, four tense situations full of panic and fear, over 80 minutes of sustained adrenaline with no release, on top of an already busy ICU call night full of septic shock and DKA.

Codes are agonizing. Only about 20-30% of in-hospital codes survive 24 hours, so it's a situation that destined to have a bad outcome. When I first started running codes, I did not save anyone through my first twelve. I was ready to quit residency. I should've gotten at least three of them to come back, if only for a day.

And then there's agonal respirations. During the code, it's a good prognostic sign, but after the code? It's probably the most horrifying physiologic response I can imagine. Every now and then you hear about someone coming back after being the code being stopped, but for the most part, agonal respirations are like a knife in the back.

And it's bad enough to have a patient die, but then facing the family is that much worse. It's like tearing your heart out piece by piece. It's always the same. The wife drives in to the hospital at 3 AM, still in her nightgown, sitting patiently at the nurses station with a cup of disgusting coffee which she can barely hold onto. And to have to tell this poor woman that her husband of 40 years is dead? It makes me nauseous just remembering.

There was another resident in the hospital who helped me through some of the codes, and in the morning before checkout, we reminisced about our terrible night. He loved vasopressin because you can't chase it with epi for five to ten minutes, so that's five minutes you can sit back and think. That doesn't sound like a lot of time, but if you're running the code, five minutes is a lifetime.

"Man, I love vasopressin. Five to ten minutes? That's half the code right there! It's Code Blue cruise control!" We both chuckled. Not that there's anything funny about watching four lives slip through your fingers, or telling four families that their loved ones were dead. It's just that when you have no other protection, nothing to hide behind, all you can do to keep going is to laugh. Because laughing is breathing, and on some days, it takes all the effort in the world to take that next breath.

Fin

Lately, I've been writing all my posts on paper and trying to edit them. I've been a little more concerned with my writing style, etc. but I've been discovering that I just don't have anything to say. I'm feeling good about my career and where I am professionally. I just don't have much to say.

And the things I do want to say are all things that I can't talk about for one reason or another. And this is just too restrictive a medium.

Finally, my personal life seems to be more of a concern to me than anything else. I was talking to a resident a while back, and he was telling me that he doesn't have time for his personal life. And from my own experience, I couldn't help but say that you can't just have a professional life. There needs to be some balance. That's something that I'm still missing.

So, for now, I have nothing left to say. And honestly, I was thinking about taking this blog down, but I couldn't do it. I don't know what this blog means to me anymore, so I'm giving it a rest.

Why I love beef

The story of vaccine is such a good story. Vaccine comes from the Latin word for cow 'vacca.' Why? The first vaccine was created by Edward Jenner. He observed that milkmaids were less likely to catch smallpox. What was it about the milkmaids that made them less susceptible to smallpox? The milkmaids were exposed to cowpox, a similar virus. He rationalized that exposure to the more benign cowpox was protective against the deadlier smallpox. So, he isolated the cowpox virus (vaccinia), injected it into people, and for the first time, people were vaccinated. All thanks to the cow. We don't call it being 'Jennered.' You're vaccinated.

There are other good stories in medicine. Pasteur was discovering germs. Lister was cleaning his surgical instruments. Beyond being good stories though, it's useful to remember their contribution to medicine. Their amazing discoveries are now barely worth mentioning in medical school because they are so self-evident, but that is the sign of a great discovery. It's right under our noses. It's also a good reminder that our current safe boundaries were once unknown frontiers.

Biggest winners

I was shocked when I saw the TV show, "The Biggest Loser." These people were competing through weight loss, and it was astonishing to see people distraught over only losing 2 or 3 pounds in a week. Healthy weight loss is one pound a week. These people are losing 5 to 10. Healthy weight loss represents a change in lifestyle. It's a marathon, not a sprint.

But even worse was that these folks were crying and feeling horrible about not losing enough weight. Losing weight and being healthy should be a positive, happy thing. It shouldn't be about feeling bad.

One of my patients was upset that in 3 months, she had only lost 5 lbs. but I was happy for her. "If you lose 5 lbs every 3 months, that's 20 lbs a year. You keep it up!" Those are the folks who are winning, nickel and diming their way to better health.

No choice

As a doctor, my whole life is making decisions. On an average day, I am deciding if I need to start another BP med, whether this lady should be admitted, if this guy needs an EKG, if I want an x-ray or a CT scan, if these medications are safe together, if I should give this patient with drug seeking behavior any more Vicodin. There are a lot of decisions, some of them easy, some incredibly hard. These choices can be the difference between life or death, and can have a huge impact on people's lifestyles or wellbeing. At times it can be pretty stressful.

So, when I go on vacation, it doesn't matter where I go as much as what choices I have to make, because once the pager is turned off, so is my decision making engine. Over one of the holiday weekends last year, I went on a short vacation, and people kept asking me what I wanted to do: when to eat, where to go, what to do, what to buy, what to drink... and finally I said, "No more decisions!" I don't want to make any decisions! Don't give me any choices!

Some people want to go to someplace fancy or unique or whatever in order to relax. For me, relaxing is a chance to get away from making any decisions. I just want to be told what to do. And that is surprisingly wonderful.

Reservations for one

place setting by paul goyette

One thing I love is good food. I am a bit of a foodie, and I have expensive tastes at times. Whenever I go out to eat, I can taste the good food. It's not too hard to tell when food has been frozen or pre-made. It's even easier to tell when something is burnt.

The problem with a love of food is that I can't eat at nice places. I don't mind eating by myself. I do it all the time. I tend to get a lot of work done when I eat out. And I don't mind going to slow restaurants and generating some easy money for wait staff. However, good places are busy, and busy places don't want to see 'party of one' on their booking. I know places that won't take that reservation.

There are many reasons why. One person's food takes as long as two, so the turnover on the table will be similar, meaning the restaurant loses the revenue of an entree and drinks. The server still gets a tip, but of a lower total. One person (if they're not a pro and bring some homework with them) has nothing to do but watch the clock, so they will notice late service. There are all kinds of reasons why a restaurant doesn't want my business.

But it's a little sad. Every time I go out to eat, it's frozen food, hastily prepared, without creativity or thought. It's depressing. I have to go home to eat well. When you've been single as long as I have, you start to miss things like eating at nice restaurants.