Do the right thing

One of the very first morality lessons we learn in life is that morality is not dependent on observation. Quite simply, we should always do what's right, not just when people are watching. This sounds pretty trite, but in reality, this can be really hard sometimes.

As a resident, I had a patient who was critical, and the family for this patient was so irritating. I just couldn't stand them. And I knew that if I played my cards right, I could convince them to change the patient's code status to comfort care, so the family would get off my back, and I could get some sleep on call.

As a student, I could've written all of my notes without ever examining my patients. No one was checking the accuracy of my findings. Who would've ever known?

And as an attending, I find myself put into dubious situations, where I am presented with disability or FMLA forms or other nightmare paperwork, and it would be so easy to just check off a few boxes and call it a day.

Unfortunately, you can't do the right thing only when it's convenient. And so, sometimes medicine sucks. No one ever said doing the right thing was going to be easy, but it makes it a lot easier to sleep at night.

TMI

Medicine is all about making decisions, but in the course of medical education, we are never actually taught how to make decisions. It is implied, as if this is a skill that we come born with. But that's not true. You have to learn how to make a decision.

The one thing that so many doctors experience is not a lack of information, but too much. We gather reports, lab tests, x-rays, repeat x-rays, repeat lab tests, consultations, and all in the effort to make a decision. And as we hem and haw, the issue becomes moot. We are paralyzed by information. And suddenly we are second guessing ourselves, and withdrawing previous decisions, favoring another.

And most of the time when we're paralyzed like this, we end up being right by doing nothing. Voltaire said it best: "The art of medicine consists in amusing the patient while nature cures the disease."

If you like to read Malcolm Gladwell, he writes a lot on decision making, and all the things that we use to make a decision, and it is scary to realize that what I had for lunch that day may be more influential to my plan of care than anything in the patient's chart.

Risk averse

One quality that is great in general internists is risk aversion. In my experience, general internists do not like to take chances. We play it safe. We measure twice and cut once. We are safe people.

In practice, that means we avoid risky behavior. We go with the established method. We recheck test results. We say things like, 'Don't trust the radiology reports. Look at the films yourself.' In reality, if the radiologist missed it, what chance do I have? We also preach from the rooftops about evidence based medicine. We know what we know. We are applied epistemologists.

But the problem with risk aversion is that I've taken it to another level in my personal life. I am totally gun shy. I like to gamble, but it's nickel slots. I like fine dining, but won't venture past five restaurants. I haven't asked a girl out in five years.

Regardless of the reward, I'm unwilling to take risks, and that is a quality that probably drew me to internal medicine in the first place. I'd be a terrible surgeon. But personally, my life is empty. Without risks, life is shallow and empty. I have no excitement, no joy. It is strange that a quality that helps so much with my professional life can be such a limitation in my personal life...

Thanks

Sometimes, it's hard to say thank you. But I've got a lot to be thankful for. I've got a great job. I'm doing well financially. My life has achieved a good measure of stability. However, stable doesn't always equal good. One attending quipped to me as an intern, "All vitals stabilize and all bleeding stops... eventually." (For those of you not medically inclined, bleeding eventually stops when you've bled to death, and similarly, vital signs like pulse and blood pressure eventually stabilize at zero)

My life has reached a measure of boredom and stagnation that is difficult to stomach, even for myself. I've become completely still. I have nothing in my life to enjoy or anticipate. I am, in a word, bored.

And I think about what I want, and I just don't know. Should I be thankful that I'm not going through all the heartache I've lived through before, and that I've found a place of emotional stability, or should I be totally dissatisfied that there is no joy in my life?

The answer, as usual, is in between. I am thankful that I have a good job and a life that is calm and peaceful. And I am sad that I am so dissatisfied with it.

Positive teddy bear sign

If you don't believe me, do a Pub Med search. There is something called a teddy bear sign. It is positive when a patient is found to have a teddy bear at bedside or in bed with them. It usually indicates that the patient is regressing to childhood and also has a high likelihood of non-organic disease. Of course, this only applies to adults. I don't think anyone would fault a six year old for finding comfort in stuffed animals.

However, the teddy bear isn't the only signal that your patient is going to be trouble. Here are some signs that I know of, some of which I've read about, others are my own creation.

Parents Sign is when someone over the age of 40 is found to have their parents at bedside. Always bad news and along with the teddy bear sign often represents mental and emotional regression.

Scrubs sign is when a patient in the hospital is dressed in scrubs, a sure signal that they've spent so much time in the hospital that they start requesting clothing instead of the gowns.

Retrobulbar micturalgia is a screening question used for patients with a 'positive review of systems' syndrome. You ask, "Does it hurt behind your eyes when you pee?" and if the answer is yes, your diagnosis is confirmed.

Radiology sign is when a radiologists marks an x-ray so that even an idiot internist can interpret it.

The radiographic criteria for fibromyalgia are (1) at least 2 MRI scans of spine (count each spine segment, so a CTL scan counts as three), (2) carrying the MRI films and/or reports to initial visit, (3) need for Xanax or Ativan (by name) prior to MRI and CT scans, (4) symptoms in distribution contralateral to radiographic findings. Criteria are met if 2 of 4 findings are present.

Can you think of any others? Most of these are pretty cynical and jaded, but I have to admit are good for a chuckle.

Here's to your health

There are a lot of opinions about how to improve health care in America, and I won't go into my own partisan views, but one thing is worth mentioning. All the discussion about national health care ignores a very basic fact about being healthy in the US: improving access to health care doesn't actually improve health. It helps with secondary and tertiary prevention (finding disease and preventing complications from those diseases), but it doesn't do anything to prevent those diseases from developing.

Nobody wants to deal with the roots of health disparities, but the ugly truth is that poor people are less healthy than the wealthy. The poor don't eat fresh vegetables or whole grains, don't work their dream jobs, don't live in gated communities, don't run for fun, don't shop at Whole Foods, don't know about trans fats. The poor simply do not have the means to be as healthy as the rich. The poor have less control over their financial future, their living situation, even their own personal safety. All morality aside, the poorer you are, the worse your health.

Having universal health care won't fix that. Improved access and more doctors won't fix that. Changing the Medicare and Medicaid pay structures won't fix that. If being poor is the primary constituent to the dramatic health disparities in the US, then the only fix is to change what it means to be poor and rich. Now, if that sounds alarmingly Communist, that's because it is.

I would argue that Capitalism creates health disparities by creating social inequality, and as such, is intimately tied to how we define ourselves as a nation. Thus, it becomes a fundamental question of identity to ask if we are willing to accept this. Because the alternative is to be socialist.

It gets easier... right?

I had the chance to talk to a budding medical student last week, and it's strange to see the medical student perspective again. When I was going to medical school, I had a very self-centered experience. That is to say, I did not notice a lot of what was going on around me because I was so focused on what I needed and wanted.

Now that I'm done with the medical education process, I find I have remarkably little sympathy for the plight of the medical student. Everything seemed so dramatic at the time, but the thing about medical education is that every subsequent year is worse. MS2 is worse than MS1. MS3 is worse than MS2. MS4, while easier from the education side, is far worse with interviews and rank lists and the Match. PGY1 is pure hell. Subsequent PGY's are painful for new and horrible reasons. Being an attending is a whole new basket of terrible issues.

So it's hard to be sympathetic when medical students complain about med school. It's like complaining to a major league baseball player that a 70 MPH fastball is hard to hit. Yes, it is, but if you want to go forward, it doesn't get any easier. In fact, it only gets worse.

Caution if hepatic impairment

I was editing and reposting old entries from the old server, and ran across a post that reminded me of something I'd tried to forget. I had a patient in the ICU, barely holding on to life, with diffusely metastatic cancer, suffering not only from all the complications of the cancer, but all the side effects of the chemotherapy, with cardiomyopathy, neutropenia, anemia, and a host of other terrible side effects.

Even with inotropes [drugs that make the heart beat stronger] and pressors [drugs to increase blood pressure], her systolic pressure was a laughable 60 mmHg. She was having end organ ischemia, and her liver was failing. Her AST and ALT were in the 1000-1500 range. Her renal function was non-existent.

And as a result, we stopped all meds that were toxic to the kidneys and liver. That included her prozac. And every morning that she was conscious, she begged me for her prozac, and I had to tell her that her liver couldn't take it. Her organs weren't working. But she would beg me to give it to her.

Eventually, my attending started the prozac again, despite the miserable state of her liver. 'Ifinding, why not give her the prozac? With everything else going wrong, why not let her have this?' And I felt real guilt. I had been trying to protect this patient from the possible toxic buildup of the drug, but I had taken away the only thing that had made her life bearable. I was worse than the chemo.

And I learned then that the compassionate choice is not always the most medically appropriate, but far easier on the soul.

Gunners

I have a friend in med school, and he is continually worried about gunners. He's started clinicals and doesn't want to be shown up or embarrassed on rounds. To me, it's quite amusing listening to students complain about gunners, because it's all perspective.

When I was on internal medicine as a student, there was another student on rotation who was always chipping in or talking about some obscure thing he'd been reading about. He knew MY patient's labs, just in case I didn't. It's not like he told me the lab values. He just got them so that if I should falter, he'd have them ready so that he could look good and I would look bad.

But looking back on my surgery rotation, I showed up earlier than everyone, did all my pre-rounding, and helped the interns with pre-rounding, and I volunteered for all the dull procedures. I wasn't trying to shine. In fact, I just wanted to do my time and be done with it, but because I put in the effort, I was always first in line. 'Hey, ifinding has scrubbed in on like five lap chole's this week. He should get to come in on the Whipple.'

I had no desire to do surgery. Scrubbing in on the Whipple was six hours of absolute torture. I wasn't trying to show off or make other students look bad. I just wanted to have a good experience. After the rotation, I found myself complaining about gunners, and one of my friends elbowed me, saying, 'Yah, takes one to know one!' I was shocked, but after a while, I saw it. I'm a gunner too. Being a gunner is all a matter of perspective. We're all gunners.

Countdown to July 1: Attending

The last July 1st with any significance is after the last year of residency. At that point, a resident (AKA house officer, physician in training, indentured servant, scut monkey, etc.) completes his training and is board eligible. If you ever wondered what BCBE stands for, it's 'board certified / board eligible.'

Uniformly, residents discover that they have a limit to the amount of residency they can take. After a certain point in time, residency becomes intolerable. It is a continual nightmare having your judgment questioned continuously, and having your clinical decision making process derailed by someone who potentially knows less than you. In fact, most residents in their final year may know as much if not more factual medical knowledge than their superiors.

But practicing on your own is a different beast. There's no one questioning what you're doing, but there's also no one to offer advice or reassurance. There's no superior to appeal to.

It is an intensely isolating experience, and all those years of medical school and residency suddenly feel very empty. I thought that I was ready to be an attending when I was done with residency, but what I discovered was that there is no preparation for being your own doctor. At some point, you have to trust that you are right, and that can be hard to come by.

Advice to the new attending:
-Sometimes making any decision is more important than being right.
-Never let them see you sweat.
-Do not pull the 'Who's the doctor? You or me?' card unless you really mean it.
-Most importantly, trust no one.

Countdown to July 1: PGY1

It is somewhat common knowledge that if you're going to pick a day to avoid the hospital, July 1 is the day. The hospital is awash with not only new interns but also senior residents still green with inexperience. And if you are a PGY1, welcome to Hell.

I remember the day after I graduated medical school, I was driving down the highway and saw a car run off the road and crash. As I drove by, I thought to myself, 'That person could really use a doctor...' Then it occurred to me: OH FUCK, that doctor is me!

The nightmare of intern year has been immortalized in the book, 'House of God' by Sam Shem, and I am sad to say that for the most part it still holds true after 30+ years. Intern year is still the singular worst one year period of medical education.

It is dehumanizing. It is humiliating. It is frustrating. And it wipes away any confidence or boldness carried over from medical school. MS3's complain that they've never felt so stupid as during third year, but that pales in comparison to intern year. At least during third year, your ignorance didn't hurt anyone but yourself. Now, what you don't know kills people.

The training goals of intern year are to learn patient care and disease management. However, what I walked away with was this: I learned what kind of doctor I am. The intern will learn what kind of doctor he is. Is he someone who fudges records? Does he take shortcuts? Does he stay late every day to tie up loose ends? Is he overly confident? Is he gun shy? By the end of PGY 1, an intern will know what kind of doctor he is, and he will spend the rest of his career either accepting that fate or fighting against it.

Some advice for new PGY1's
-If you can, wear scrubs all the time.
-Making friends with the nurses will improve your Rounding-Fu*.
-When you go home, leave the patients at the hospital.
-Make yourself a 'Laws of the House of God' checklist.
-Finally, but most importantly, the most valuable thing I learned during intern year was: sleeping is more important than eating.

*Rounding-Fu: How badass you are during rounds

Countdown to July 1: MS3

Anyone familiar with the medical education process knows the significance of July 1st. It is the day that everyone moves up a peg. MS2's become MS3's. MS4's become PGY1's. PGY3's (or 4's or 5's) become attendings. There's a lot of significance wrapped up in July 1st.

Third year of medical school is a funny thing. It is an unpredictable experience. It is rough and wonderful and glorious and terrible. It is amazing and disturbing. And the thing about the third year of medical school is that it changes people. At the beginning, everyone starts bright eyed and eager, and by the end, students are profoundly different.

We all imagine that if we were in battle, we would be leading the charge, but what we may discover is that we are the ones hiding in foxholes, shitting ourselves. And that is what you find out about yourself in third year. You find out who you are. You discover if you are vengeful or vindictive, apathetic or aggressive, kind or cantankerous. Your own true nature is revealed.

There are many reasons for this. The MS3 is sleep deprived. He is rotating through different rotations and always a little disoriented. He has not eaten breakfast in 10 months. He has not seen the sun except through patient room windows. He has been constantly pimped about every piece of medical knowledge currently known.

Although we have been trying to change the process of medical education, the MS3 experience is still one of being crushed down, and then being rebuilt better than before: better, stronger, faster. However, that means that some soul crushing has to take place... As nice as it is to be done with the process and look back on MS3 with nostalgia, having your soul crushed is a uniquely painful experience.

Some words of advice to the new MS3:
-Take a shower, no matter what.
-Work hard, play hard.
-No one likes a kiss ass.
-Wear comfortable shoes.
-Your attending wants 3 things from you: honesty, enthusiasm, and diligence (if you have none of these qualities, learn to fake it).

Eating healthy

I often field questions about dietary supplements and vitamins. What do I think about co-enzyme q10 or high dose vitamin E or beta carotene? Flax seed? Ginkgo? Tons of stuff like that. For the most part, we don't know a lot about dietary supplements. No one has studied these things in any really meaningful way. But in reality, eating healthy is such an easy task that it doesn't require much thought.

If everyone simply did two things, then we as a country would be much healthier. If we (1) ate less, and (2) ate less packaged and prepared foods, we would be miles healthier, diabetes would be far less prevalent, and we would stop being the fattest country in the world.

...but at the same time I'm telling patients this, I have a cheeseburger with fries for lunch waiting for me in my office.

Convince me

There's a lot of science in medicine. It is often called the youngest science, and rightly so. However, the practice of medicine is quite different from most sciences because it is so intimately tied with dealing with people. And one of the problems with dealing with people is that despite whatever evidence you may have, people need to be convinced.

One of the tremendously annoying things I discovered in med school was immunization of children. So many parents had so many bizarre (and frankly ludicrous) reasons not to immunize their children. After a while, it just wasn't worth fighting over. Now, it's not uncommon to see outbreaks of mumps and measles. Measles is a disease I can't even recognize. I've never seen it.

But immunization is only the tip of the iceberg. I fought over the phone and in person with a patient over the course of a day to agree to have a cardiac catheterization. Once in the lab, they saw left main and triple vessel disease.

One of the things I love about adult medicine is simply that: it's adults. If someone wants to make a tragically bad decision, at the end of the day, if they were properly informed, it's their terrible decision to make, and I can sleep easy at night.

Keeping sharp

As a general internist, there are a few different jobs that I am trained to do. I am able to see patients in the clinic, outpatient medicine. I am able to see patients in the hospital, hospitalist. I am able to address urgent issues, emergency and urgent care. Not a lot of internists still do emergency, with the rise of emergency medicine as its own specialty. That leaves the hospital and the clinic.

Everyone has their own preferences. Some like the clinic more, others the hospital. I’m not a big fan of hospitalist care. Not that I disapprove. I just don’t enjoy it. I went into medicine for the continuity of care. However, the clinic has its downsides as well. The one true thing though is that if you do one or the other, it’s easy to get rusty. If all you do is clinic work, then the hospital is a pretty intimidating place. There’s a lot of aspects to acute care that are challenging and require a lot of coordination. If all you do is the hospital, then the clinic is really difficult. Results come back in weeks, not hours, and dealing with patients with chronic illnesses is challenging.

The one thing I’ve noticed about myself is that I’m not feeling very sharp with either. I’m losing that sharpness I had in residency in the hospital. I don’t have all the answers. I’m not ‘the man’ anymore. In the clinic, I’m not as sharp as I could be, often taking weeks to take care of relatively simple issues.

To me, it seems like the traditionalist is not a sustainable model. Precious time is split too much, and there’s no expertise. And the shame of it is that I want to be an expert at something.

The things you learn in med school

When we talk about medical school education, there's the actual didactic material, and then there's the 'hidden curriculum.' For those not familiar with education lingo, the hidden curriculum is a set of norms or values that are imparted to students unintentionally. It is not written down. It is not testable. It is simply something learned through the process of going to medical school.

In medical education, some examples of hidden curricula are that men shouldn't go into OB/GYN, or women shouldn't go into surgery. You should have no life other than medicine. Everything comes second to your medical responsibilities. Sleep is for the weak. There's no crying in medicine.

Sometimes, these lessons are reinforced though things like lectures on professionalism or the patient-physician relationship. Some schools even try to direct their hidden curricula, taking it into the open light, for better or for worse.

For me, I found my own hidden curriculum from medical school. In the process of going through school, I learned a lot of things that med school never intended to teach me, but they're some strong lessons for life:

The friends you make over a bottle of $200 scotch at 4 AM are probably some of the best friends you'll have.

Thanksgiving and Christmas are precious, and when you can't go home for your own family's holidays, then finding a family to take you in is invaluable.

Medical school is some of the hardest work you'll do. Work hard, but play hard too.

While there are many other such lessons, the one that stuck with me is that at some point in your schooling, you will find that you will have to choose to give everything to medicine, or hold back. And you will discover what kind of doctor you really are when you're faced with the hardest choices between what you want to do, and what other people need of you.

Who you need me to be

One of the strange things about being a doctor is that I play a lot of different roles, and I don't mean administrator or physician or teacher or whatever. I mean that when I meet a patient for the first time, I try to figure out what they need me to be. Some patients need me to be a listener. Some need me to be a father. Some need me to be a counselor. Every patient needs something a little different.

One of my patients is a university professor, and what he wants from me is advice about the stuff he reads about health. Is there any truth to coenzyme Q10? Is Atkins a good idea? He doesn't want me to tell him what to do, just give him some advice.

Another patient has no clue. She comes to me without any idea of what to do next. You need to lose 10 lbs. You should cut out fried foods. When you can't breathe, you should use your inhaler. I saw one person who just wanted reassurance. He knew and I knew that he was healthy, but he needed to hear it from me. Another needed me to boss him around.

The strange thing is that I am simply me. I don't try to act like someone I'm not. And somehow, that's enough. I think that the quality that lets me do this effectively is that I don't need to be in the driver's seat of the patient-physician relationship. Tell me what you need me to be.

Anhedonia

In order to truly enjoy something, it has to have some context. It has to be shared. That's why people try not to eat alone or go to the movies alone. It loses its context. And that is the dilemma of my life. I lack context. I have all these emotions... is it hate or love or envy? I can't quantify or measure it. It's like a commercial: it happens, it's over, it meant nothing, and it's forgotten.

When we talk about anhedonia in the clinical sense, this is not it, but I wonder sometimes if this is real anhedonia. Everything is bland and grey and lacking passion, not memorable at all.

I'm not depressed, although my friends seem to think it's within the realm of possibility. I just feel like my life needs more context.

Don't become a doctor #14 - Uncertainty

The first time anyone told me that something was unknowable was in science class when I learned about the Heisenberg Uncertainty Principle. You cannot know the exact momentum and position of an electron at the same time.

Well, surely, with better tools and more precise ways of measuring... "No, no, no, you don't get it!" My p-chem professor had crazy, uncombed hair and he had missed a button on his shirt. All the buttons were off, so it was hard to take his words seriously. "A thousand years in the future, with the best tools available, we will never know."

Medicine is not without its own uncertainty. And that doesn't sound so bad in an academic sense, but it's not very comforting to patients. How do you tell a patient that you don't know? I don't know what's causing your abdominal pain. I don't know if it's from your heart or if it's acid reflux. I don't know.

As a practicing physician, I've gotten used to it. The students seem to have a much harder time with it. As a resident, I worked with a group of students, and uncertainty was a problem...

"So, is it Buerger's Disease?"
"Excuse me?"
"The case from this week, Buerger's Disease, right?"
"Oh, the case. There's no answer. It's just an exercise."
"But we were supposed to think about Buerger's Disease."
"It's in the differential, but there are lots of possibilities."
"But it's really Buerger's."
"Well, there's no answer."
"How can there be no answer? It's Buerger's Disease!"

In medicine, there are lots of questions where we never get any answers: poorly differentiated tumors, diseases without any diagnostic tests, all sorts of situations without clarity. Sometimes we spend time and energy to try to find the answer. Sometimes we don't even bother. But the truth is that in medicine, there is uncertainty on all sides.