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 story of pharmacy girl

While I was on general medicine, there was a girl working with the pharmacy who I'll call pharmacy girl. She was very bright-eyed and cheerful, and had this ebullient personality which was so very attractive. I have to admit that I was smitten, and when I say smitten, I mean smitten with every possible negative connotation. I had some sort of bizarre, junior high, blushing cheeks and stammering speech infatuation that lasted a brief couple weeks, but then she was gone away to perform some other pharmacy related service, and I didn't see her again.

However, I thought about her and how she defied all of my previous stupid crushes. She wasn't haughty and dismissive. She wasn't emotionally unavailable. She smiled. She was friendly and outgoing. She was (dare I say it) somewhat normal.

So, I saw her again recently, and we talked for a bit while I was going over a chart, and we chatted pleasantly, and she had a negative left fourth finger test, and I thought to myself, "Ask her out. Give it a shot. Worst she can say is no." We seemed okay. We could have some chemistry. And so I scrounged up a little nerve.

Or I tried to find the nerve, and there was none there, so I said good-bye and left the hospital. And that is the end of the story of pharmacy girl.

Apparently, I'm a jerk

Patients LOVE me. I mean it. I'm not being facetious or pumping my ego. At least once a week, I have a patient talk me up, or try to get into my residency clinic. When I was still taking patients, I had to turn these people away out of fear that I'd be accused of poaching. Even today, a nurse told me that one of the patients I saw a month or two ago, this patient saw me in the hall, and the patient couldn't stop talking about me.

So, I was a little surprised to find out that apparently, I'm the jerk senior resident. I'm the guy that yells at the interns and is too critical. I'm always in a bad mood and never fun to work with. I make the interns work too hard. No one wants to work with me.

And as much as I'd like to deny it... it's TRUE! I'm a jerk! How dare I make the interns work, and demand that they meet a standard of excellence? I'm such an asshole. I am the Dr. Perry Cox of my institution (except I'm nice to patients). If you're an intern, let me tell you how to stay off my shit list.

1. Don't lie about your skills. Nothing pisses me off more than an intern misrepresenting his skills. I've had interns tell me they were experienced with central lines, only to find out that I was supervising their first attempt at a CVC. Not cool. I don't mind teaching a procedure, but I need to know that you don't know.
   
   
2. Don't complain about working. I've had interns complain and whine and bitch about doing FOUR OR FIVE admissions. Christ! Who the fuck complains about that? Compared to my intern year, these guys are getting off light. I've got absolutely no sympathy. If you didn't want to work hard, you should've become a janitor.
   
   
3. Mistakes are okay. Stupidity is not. Not knowing which antibiotic to use, that's okay. Not knowing which stress test to order, fine. Not being able to write an H&P, that's a big fucking problem.
   
   
4. Fucking up is okay. Being lazy is not. You're an intern. You'll make mistakes. That's FINE. What is not fine is not doing something because it is inconvenient. I have actually stood at bedside and made interns do rectal exams on patients when indicated, because not doing one when it's indicated is practically criminal. I've been so adamant about this that several interns think I have a butt fetish.
   
   
5. Don't help unless you know that your efforts will actually help. True story. I put in a central line, showing the intern how to do it. While I was sewing it down, he tried to clean up my sharps. I didn't notice. Then he gets paged away. I turn around and I can't find the guide wire. SHIT. SHIT SHIT SHIT SHIT SHIT SHIT. By the time he got back, I had a 911 page out to vascular surgery and super stat portable x ray.

I had a coworker in college. I was applying for a student supervisor position at the job, but he begged me not to do it. Why? "Ifinding, you're a good guy, and you would be awesome at supervisor, and I have no doubt that you'd get all kinds of stuff done, but it's a part time college job for beer money. You'd never let us be lazy. You take this too seriously."

I think the same is true now that I'm a senior resident. I demand a standard of excellence from my interns, and I'm not talking about technical proficiency. I'm talking about integrity, honestly, respect, humility, and compassion. These are requisites to being an excellent doctor. And if you're not interested in being an excellent doctor, I'm not interested in teaching you.