Stress in Medicine

How do I cope with the stress of being a third year medical student?

At first I drank a lot. Alcohol. Beers and wines and champagnes and liquors. But hangovers in surgery don't mix. And then I remembered what our physiology professor had told us last year in a off-handed comment, about how alcohol abuse is very common in medicine. Well, I don't like following trends, so... I should find something cooler.

Then I tried caffeine. Not like coffee or tea. Like, obscure effervescent caffeine pills with added vitamins and minerals that you can only buy in Europe. They were citrus flavored but they tasted like chalk. And then I had a caffeine withdrawal headache. It was not fun.

So then I smoked a lot. Not cigarettes, because cigarettes kill. Every first year knows that. I smoked  e-cigarettes. And boy, they are so much cooler, because they light up when you inhale. But nicotine doesn't really do anything for me. So I stopped buying them from drug stores.

I've tried various vices and engaged in some virtuous activities, but the stress of third year is something that is impossible to deal with. Sometimes I just forget about all the things I have to fill out and send in, and just focus on what I'm doing right now. Whether that's playing games on my smart phone or hanging out with patients in waiting rooms, it doesn't matter. It's me time.

An Update--Emergency Medicine

So I haven't written anything in a while, but I am feeling particularly happy today, so maybe I should post up an update on my life.

I finished neurology a while ago... three weeks ago, actually. It was a good rotation--although it was so boring and we saw so few patients at our rotation site that I actually managed to read about 75% of our recommended text book (the most I've ever read of a text book ever!) [12.20.13 Update: Turns out I did well above average on the Neurology shelf exam, suggesting that contrary to my hopes and wishes, patient care does not help you learn. Textbooks do.] The clerkship director is both nice and sarcastic, wise yet modest. He also has a beautifully maintained walrus mustache. Irregardless, I learned a lot and finally feel competent in at least one clinically relevant thing: the neurological exam.

I didn't realize how important that would be until I posted up in Emergency Medicine and found myself running through the neuro exam in approximately half of my patients. Strokes, seizures, headaches, falls and other assorted traumas--a lot of what passes through the emergency room requires some neurological assessment, and for the first I actually feel semi-competent in something. Also adding in my understanding of vasculature from surgery and my knowledge of medications and bedside procedures from internal medicine, and I sometimes--occasionally--feel like an actual medical student, no, an actual physician.

My favorite thing about Emergency Medicine is that I get to see my own patients before anyone else--and I get to physically examine them. I have no choice! It's a requirement I can't get around! Now that I am forced to see people on my own, I have actually developed some strategies to forming good rapport with patients. Of the thirty odd patients I have seen so far, only one of them has been difficult and unwelcoming. Everyone else--even when they are in excruciating pain (manufactured to receive dilaudid or otherwise)--has been incredibly nice to me or at the very least incredibly tolerant of my prodding questions and my poking hands.

A few encounters stick out to me in particular, and I guess I'll review them below:

Linda the Finger Lady
So this is a fun fact: BOTH OF MY PARENTS ARE SURGEONS. Because of this, I feel over competent in my ability to suture. Or at least, I did until I was asked by my clerkship director to suture shut a centimeter long laceration on a patient's pointer finger. I observed the clerkship director inject a ton of lidocaine without epinephrine into this woman's finger, then I was left alone with the suturing kit and Linda. It was an overnight shift. During the day, there are enough attendings and PA's around that suturing is done by the more competent. But it was two-thirty in the morning and I had already stitched a guy's hand exactly six days and twenty-two hours ago, so dammit! I felt comfortable in doing this myself.

Linda, as it turned out, was incredibly friendly. But she was also incredibly sensitive to pain. I couldn't blame her, of course, because fingers are very sensitive things. But as I was still analyzing the pad of her finger--trying to determine how to best suture a tiny laceration with subcutaneous fat spilling out and making it difficult to stitch--Linda began to wince. The lidocaine was wearing off! And I still had at least one more stitch to go. I could have grabbed the lidocaine and given her another shot--but since lidocaine shots are the only part of the suturing process that is painful to patients, I felt uncomfortable causing Linda--who had been sharing small, humorous anecdotes of her life while I pondered and sutured the wound--additional pain. So I rushed out of the room and found the clerkship director.

"I have a problem!" I blurted out. The attending casually turned around so that she could stare me down despite being almost a foot shorter than me. "The lidocaine is wearing off and I used up all of the suture material." I was embarrassed, of course, but I know when to admit defeat--when your actions, no matter how minute and insignificant, could potentially get the hospital and attendings sued. "You ran out of suture material?" She asked, cocking her head slightly to further inspect me, although I was uncomfortable making eye contact and was instead staring at her ID badge that announced she was a medical doctor. She had already turned around to walk to the suture crash cart as I said, "I guess I wasn't judicious with my ethilon."

I followed her back into Linda's room, closing the curtain behind me to deny the few people left in or unable to sleep in the emergency department. As the clerkship director injected lidocaine and began suturing the rest of the laceration--still opened and unable to heal properly. I panicked a little when she took the small scissors from the laceration kit to cut out one of my three stitches. How embarrassing! On her last stitch I turned to face Linda, placed my hand on her shoulder and said, "I am so sorry." Linda told me several times that I had nothing to apologize for, but I still felt bad that I had hurt her because I wasn't quick enough with the stitch.

I felt as though I had disappointed both the attending and the patient. As we left the room to sit at a computer terminal, I made a mental note to myself: "For the sake of Linda, I will get better at suturing.

The Old Man on Coumadin watching the AMC Turner Classic Movies channel
Literally the next day my emergency medicine attending found himself with his hands full--a patient who's doctor had yet to fill out her DNR paperwork had fainted and her heart had entered ventricular fibrillation. Much of the day was spent counseling the patient's family and calling other doctors to figure out what we could do for an unresponsive person. I was sitting at a computer terminal twiddling my fingers when my favorite attending told me that she had a patient that required sutures. I jumped at the chance. He ended up being an eighty year old man on coumadin who had had a mechanical fall and formed a six inch long laceration on his forehead. She informed me of several things:

• How to properly inject lidocaine into a patient--even if they are screaming from the pain.
• Digits and ears and noses should not get lidocaine with epinephrine--this can negatively affect circulation, leading to poor healing or gangrene [12.20.13Update Although later a plastic surgeon will inform me that the epinephrine wears off in about 1 hour, and considering you can reattach digits 12 hours after they've been amputated with acceptable deficits, 1 hour of poor circulation is worth the benefits of epinephrine (less bleeding, longer effect of local anesthetic).
• As a student, I should pick up double the amount of sutures I think I actually need.
• Especially if I am using 5-0 ethilon, which is not much thicker than a strand of human hair.
• Irrigating the wound is essential.

Anyway, the man was mildly demented, so besides moving his hand to rub his nose twice, he did not interact with me at all as I put in 11 stitches while watching a black and white film about zapatistas. AND THEY WERE BEAUTIFUL STITCHES (the movie was also beautiful). It took a lot of self-restraint to not pull out my phone when I was done to take a picture of the closed-up laceration that had been spilling thinned-out blood for the last several hours. I cursed the fact that the clerkship director would never discover that I wasn't actually terrible at suturing. But I was still proud that I had stitched well completely unassisted.

The Seizure in the Random Genetic Disorder Patient
Another overnight call and at four in the morning the EMT's stroll in with a woman holding onto a small child, both laying on a stretcher, bundled up in blankets against the cold. Five or six minutes later, my attending turns to me from his seated position behind a computer, and tells me: "It's a pediatric case with seizures. Most likely febrile. You're up." Ever enthusiastic about my pediatric cases (seriously, you see no children in surgery, medicine, or neurology) I bound into the room and am immediately struck by something. Amelia. The child has no hands, no forearms. One arm has a single digit sticking up into the air around where the elbow should be. The other just ends at the humerus, the skin sharpened into a point akin to a what a wing looks like on a rotisserie chicken. I stop cold in my tracks. Six hours ago I had finally had a child as a patient who didn't immediately cry at the sight of my white coat. I was enthusiastic because I could stand next to him with my stethoscope for auscultation without him crying his eyes out making heart sounds and lung sounds inaudible. I think he even smiled at me. I had no problem getting into the kids face. Now I was uncomfortable and didn't know how to proceed. But within a few seconds of observing the nurses buzz around completing their tasks, I realized I could just treat this child the same way I treated another kid who presented with fever and vomiting two days ago--and who began crying whenever I got within five feet of her--I would just talk mostly to the parents.

It turned out that that was the most I could do, since the child was non-verbal. Still, I kept feeling as though I was offending the mother in some way. The kid was cute, actually, but since I got the feeling she couldn't understand me--or even pay attention to me--talking directly at the child would be of little benefit. Usually, even if someone is very opposed to me examining them, I attempt a few maneuvers--heart and lung sounds. Now I just stood around and asked history questions from the guardians, realizing more and more that this probably wasn't a febrile seizure like my attending had suggested.

I left the room to confer my results with the doctor, which could be summed up in one sentence: "this kid is a lot more complicated than you thought." The attending agreed--while I was asking questions and observing the patient, he and the scribe had been looking up the patient's past medical history in the computer. We all walked back into the room to talk to the parents. I paid more attention than usual at how the doctor talked to the family, but just like almost every other patient-doctor interaction I'd observed thus far, it was more fluid--and in this particular doctor's case friendlier--than any medical student-patient interaction.

What hurt me though was when the doctor started breaking down the plan. At one point he said something like, "If this was any other kid, we'd do x-y-and z to rule out causes for her seizure." The mother at this time began crying. "I want you to treat her like you would treat any other child," she said. It wasn't very logical. Before proceeding with the plan, we should confer with the patient's pediatrician who would likely be more knowledgeable about the sequelae of the disorder, in which seizures are more common. That would be more efficient. We wouldn't have to irradiate the child as much by subjecting her to a CAT scan. But in that moment I realized that the child wasn't simply cute despite her genetic disorder. I realized she was cute because her parents had cared so  much about her that they had spent the time to brush out her hair and braid it into pigtails, to dress her in a nice outfit, to hold onto her no matter what. More importantly, they made it much easier to connect with someone who can't speak. It was heart-breaking and endearing. Also insightful. We are not so much our genes as we are the effort our caregivers put into us. Which is why, despite her disorder, this young girl was more fortunate than many of the drug addicted individuals who had no choice but to enter the emergency room, broken and useless, still suffering from psychiatric illnesses implanted in childhood. [1.6.2013 Update: Ugh. So depressing.]

The Emergency Room Tech and... I'm not a Physician Assistant student, sorry.

I was just standing around minding my own business. A woman decked out in scrubs and holding onto a medical device on wheels, was awkwardly looking in my general direction. I get this behavior a lot from patients' family members who want to ask me questions about the care of their loved ones and if it would be okay to leave and come back later after we've run our tests. But this was the first time I had noticed a staff member staring at me. I acknowledged her presence by making direct eye contact and she walked over to me, invading my personal space. "What are you studying to be? A PA?," she mumbled quietly. "Um... no. I'm a medical... doctor... a med student. Why? Am I not good enough for you?" I asked. "No. It's just that there's something going on with my ears." "Oh, I know how to do an otoscope exam." I said, slightly offended. The tech than smiled and said, "oh well then, follow me." And she dragged me into the nearest abandoned emergency room, darkened due to the absence of patients. Progressive worsening of sinusitis with ear involvement was the indication for the exam, and I found nothing. Ha. Med students can do something... like assessing the general appearance of tympanic membranes.

Delirium Tremens

First off, let me just say that I have seen many more cases of alcohol withdrawal and potential delirium tremens in the white people of Libertyville and surrounding commons than in the inner city patient population of Mount Sinai. I'm going to go ahead and assume that all cultures abuse drugs at roughly the same rate, but every group has their own preferences. Sadly, a lot of the alcohol withdrawal patients I saw at Condell were middle aged white women. I've developed an attitude towards (upper) middle class white women who stay at home all day. My mom is an upper middle class white woman.... but who has also been fully employed for my entire life. She's not a stay at home with a raging drug addiction.... although as a female surgeon she does drink quite a lot. Regardless, I had so much bitterness in me towards this demographic of rich white women without jobs and without purpose, living cushy lives without fear of poverty, that I was actually surprised when I went in to see a middle aged, middle class, white women, vomiting profuse amounts of saliva into the pink plastic bucket she held in her tremulous hands, and wasn't immediately morally disgusted.

As I presented the patient to my attending, and the other doctors and scribes discussed their complete misunderstanding over why anyone would drink so much, I realized that I cared a lot about this woman because clearly no one else could. "She's actually quite pleasant," I had said, to which my attending responded, "For now." 

"Oh," I added, "And she actually wants to quite drinking."

"I'm sure," she had said, sarcastically. I laughed nervously. Then spent the remainder of my shift trying to find resources for the patient. Her daughter and her mother had been in the room with her. I couldn't believe the attendings all sounded so jaded. Or maybe I'm just naive.

Whatever the case, I learned something important about emergency medicine which will keep me from considering it as my profession. As an EMED doctor, I would be in charge of processing huge numbers of patients, finding out where they needed to go--surgery, floors, or home. You run tests, you look at scans. You figure out where they're going (hopefully not down) and you get them to go there. Simple stuff (insofar as anything in medicine can be simple). All pathologies can be thought of as puzzles, and it seems like in EMED, you kind of lay down a few tiles and get the gist of what you're looking at (e.g.: in puzzles, a horse running across a beach; in pathologies, appendicitis.) But at the end of the day, or at the end of my shift, I won't be satisfied looking at a nearly finished puzzle and admiring it. I'll be searching for the person who scattered the tiles in the first place. 

BRBPR... & hipsters

Today I realized two things:

1) BRBPR does not stand for "be right back, personal relations". It stands for bright red blood per rectum.

2) You can't spell PBR without BRBPR!

Hierarchies in Medicine

Despite my feminist background, I really do enjoy the hierarchy in medicine. Not because I think it’s helpful for anybody in the medical field, but because it makes sure there are checks and balances in patient care.

For example:

As a medical student, I have no idea what’s going on. Ever. In any given patient interaction, I will likely be the most confused person in the room. Even patient’s seem to know more about what’s going on then I do. But there’s a ton of reasons for this: my medical training is incomplete and, most likely, I’ve only worked at this hospital for a couple of weeks and I couldn’t find the nearest restroom or wherever they store tourniquets if I was offered enough money to cover my student loans.

But I’m not an idiot. I can catch errors. Very rarely I get to catch huge, major errors simply because I am the least busy person on the team. Like forgetting to order furosemide for the acute exacerbation of congestive heart failure patient. Really, it’s just an oversight. But I caught it and it changed management.

Doctors and residents are sometimes upset with me for not doing something or being “incompetent”, but it doesn’t matter, because I have an excuse: I’m an incompetent student. Whenever people give me criticism, it’s always in the form of, “One day, when you’re a resident/physician, you’ll be expected to…” which means that I’m not really expected to do much more than what I’m currently doing.

A Slave to One's Emotions

On a recent episode of The Daily Show with Jon Stewart, the guest was Michael Fassbender and he talked about his experience on the set of "12 Years a Slave." It's apparently an intensely emotional and raw movie adaptation to an actual book written by an actual person in the 1800s. Fassbender, who is hella white, plays a supporting role as the incredibly cruel plantation and slave owner. Of this experience, and how he dealt with having to pretend to be a terrible person for most of his days, he said this:

"I mean especially when you're dealing with such heavy material it's nice and necessary sometimes to have light moments in between so it doesn't become all the time heavy and you get [blinded]....
so the moments you can find relief and respite you do, and other times that require it, you stay in the moment as it were."

I think this quote describes how I deal with working in hospitals. You're surrounded by so much of what is disgusting with humanity: pain, deception, corruption, death; so much unabated suffering. On the one hand, I'd like to live in the moment and experience the pain my patients suffer with them. But on the other hand, if I did that with everyone in the hospital, I'd be so drained every day that I don't know if I could function. Both of my parents are hilarious--albeit in different ways (one's abstract, surreal humor; the other's just dark and sarcastic)--maybe that's the only way they survived medicine for the decades they sacrificed to it. 

But on the other hand, I'd like to feel with my patients so that I never stop working for them. When I turn patient's into little anecdotes, I stop caring for them. When I just stare at their assessment statement and their labs, I forget that they are people who may lighten if I go talk to them, who may benefit when I hold their hand. 

CURIOSITY//NO PRETENSE OF LINEAR THOUGHT//WHAT MAKES A GOOD STUDENT DOCTOR?

This is an interesting article suggesting that the best doctors are not the smartest or even the most "humane"... simply the most curious. It makes a lot of sense. One of my favorite things about medicine is that you are constantly learning. You have to keep taking CME courses to keep passing boards; you have to stay up to date with how disease management is changing so you can give your patients the best care; etcetera. Rosalind Franklin University's motto is specifically: "A Life in Discovery." You rarely make discoveries if you're not curious.

This was my favorite quote:

"Watching talks given by Nobel Prize winning scientists for inspiration, she noticed similarities in their ways of thinking. They all seemed to toss around ideas with no pretense of linear thought, no semblance of structure, and, perhaps most importantly – no pretense of competence."

http://blogs.scientificamerican.com/unofficial-prognosis/2012/03/08/what-single-quality-predicts-a-good-doctor/

This also reminds me of a conversation I had with my dad about how we had both learned a lot more from our medicine rotations than our surgery ones (my dad even told the head of the surgery department at the Feinberg School of Medicine (Northwestern University) that he didn't want to go into surgery because "surgeons don't know as much as internists.") In surgery you were either right or wrong, you studied on your own time. In medicine you can still be right or wrong, but you can also be close to right but not quite there yet, we're not standing over an anesthetized body and we've got the time so we're going to teach you right here right now. I love that. I love that I can think out loud and not be told that I am wrong but rather be told that I am going to learn something today. 

Besides that one day I showed up on 4 hours of sleep and severely hungover from a friend's Oktoberfest, I have learned at least one fascinating thing every single day of my rotation. 

Ode to my Intern

My intern is a terrible person*, but all in all, I think he's taught me a lot about how to deal with your intern year without completely losing your mind.

1) TAKE A LOT OF NAPS
You have a call day on the weekend and you're waiting to round with your attending in like five hours? Take a nap! Any surface you can lay down on is a surface where you can fall asleep. Direct quote from my intern: "Remember in preschool when you had those roll out sleeping pads and you had a twenty minute nap? They should make all the residents do that after morning report.

2) FIND HUMOR IN EVERY SITUATION... as long as you're standing far enough away from the patient's room.
Not going to lie, a lot of the cases we get in internal medicine are incredibly depressing. Any humor--even if it's dark--can be beneficial to one's (read: my) psyche. I am most impressed by the fact that my intern can make fun of any patient or any patient's situation, and then be incredibly, and sincerely nice to them when he goes to see them.

3) INDIANS PRONOUNCE THE WORD POTASSIUM WEIRD
Seriously weird. PO-TA-SHE-UM. Similarly they mispronounce Calcium and Magnesium. He was raised in America but still pronounces important elements like he was speaking... not Amuuurican.

4) BE A HUMAN BEING... and be humble
One of the things I was most worried about was how I would deal with being an intern. You don't know how to do everything yet, so sometimes you may feel incompetent, and you just finished your M4 year, so you may not remember everything that was on Step 1 or Step 2. But my intern just kind of rolls with the punches. I know he's learning a lot because he doesn't look anxious when he gets a question wrong, he just checks uptodate.com for an answer and proceeds to help out a patient. Also, my intern (and actually a lot of residents) goes out and/or spends time with friends. Not a lot of time, but he spends his off time having fun or sleeping (the two most important free time activities).

I am incredibly sad that I will have to leave this rotation. It's been great: learned a lot, laughed a lot, slept enough, I could not have asked for a better rotation.

Figure 1: Intern and I passing out during our post-prandial states

*His ideal patient is between the ages of 15 and 35, who is educated, and who has insurance. Good luck finding them!

star trek is actually the greatest teacher

When I was an M1, an M4 was trying to do a research project on how Star Trek could be used to teach medical students about bioethics. At that time, I had barely finished watching all of Star Trek The Original Series and Star Trek The Next Generation. Within the last month, however, I finished watching all four of the widely accepted spin-offs (I know Enterprise is cannon but everyone keeps getting so angry when I bring it up!), and as I walk around the hospital I find myself wondering what life would be like if I was instead on a starship or asking myself how one of the four doctors would have chosen to deal with my current dilemmas. 

So in honor of them, I made this art:

What's Death Got to Do With It?

I realized something today while I was hypoglycemic at 63 mg/dL and more susceptible to fear: I am absolutely terrified of death. Not that that is something new. When I was nine I watched a movie about time travel while vacationing around Mesa Verde, and I realized, at nine, that one day I would die and all my accomplishments would account for naught. More than that, I realized that an eternity of total, unyielding unconsciousness was something I never wanted to experience but something I one day would. I, personally, do not want to die. Besides the fact that I engage in a lot of moderate risk behaviors, I do not want to die. I have been suicidal twice in my life, and those events were partially fueled by untreated depression, but they were mostly fueled by my previous realization that one day I will die and everything about me will mean nothing. 

Besides the soul-crushing nihilism surrounding my personal future death, I am also reaching the age where the people I know and love are starting to die. Yet still these deaths are mostly accidental… I feel a great amount of guilt for the deaths of people close to me… those that have stolen people who are related to me by blood in particular… but I cannot change what I did, and ultimately, even though I failed to do things that may have prevented their deaths, their lives were not my responsibility*. 

Now that I am in medicine, lives are very much my responsibility. I have a feeling that this is the source of my fear. I have always been a very good liar. I sometimes attribute this to the fact that I am a natural fiction writer, and therefore I am more readily capable of producing fictional realities in my mind. But the reason why I lied when I was little, and the reason why I occasionally lie now at the age of 24 is because I do not want to let someone down… I do not want to fail.

As a result, when I encounter a patient-doctor situation where the patient might be dead, I run back to my resident and make up reasons for not seeing the patient. I have two examples of this behavior:

The first example occurred when I was asked by my team to inform a suicidal patient that he wouldn't be able to leave the hospital until he was admitted by psych and evaluated for several days. I went to the patient's room and found it empty… But all suicidal ideationists have to have a 1 to 1 sitter, someone with them at all times…. yet here was a hospital room completely devoid of people…. although the bathroom light was on… and it occurred to me that this patient of ours may have hung himself on the water line that connects to the shower head… or cut open his veins, letting the blood pool out from around his wrists, only to let is fall on the brown tiles that constitute our hospitals bathroom floors. WHAT I WISH I COULD HAVE DONE would have involved knocking on the door, and upon not hearing a response from its occupant, opening the bathroom door to see if any dead bodies were mucking around. If a dead person had been found, I surmise I would have run out into the hallway and yelled "HELP", forgetting how to present patients to healthcare professionals.

The second occasion involved a patient with chronic hypotension. My intern instructed that I run to check the patient out--ask about dizziness, measure blood pressure, assess any changes in mental status--but when I got to the room the patient was fairly unarousable… he was asleep. I knocked several times on the door to this room and on the walls containing him. I even yelled out his name. Yet he did not even twitch underneath his sheets. The next step in arousing a patient would be to apply a sternal rub--basically pounding on somebody's chest with your fingertips. But I couldn't bring myself to touch this patient… what if he was really dead? He wouldn't respond to my tapping. He wouldn't be saved no matter what medical interventions were applied to him.

In both of these situations, the patient was found to be very much alive. I was acting inefficiently when I decided to enter the patient's room only to promptly leave it when I didn't get the response I wanted. 

The death of a patient seems like the greatest insult to a physician, even scoring above having your medical license removed. It tells you that you missed something. Hell, we have M&M's specifically designed to analyzed where you as a physician failed the patient.

I don't want to tell someone a patient died because we didn't check their blood pressures often enough. I would rather lie than experience that shame and guilt.

Rules and Regulations: Is Cover-Your-Ass Medicine Devaluing Healthcare?

Today was the day I realized I will have to go into family medicine. Not because I loathe internal medicine (quite the opposite--I have loved almost every day of this clerkship) but because I cannot work inside a hospital. There are many terrible things about hospitals. They are full of sick people. And because they are full of sick people they are always full of the things that accompany sick people in societies both full of resources and those that reside in the third world: the smell of disinfectant mixed with the odor of bodily excrement--almost unavoidable if you spend a day walking around on the floors; the screams... the tortured moans of patient's suffering either from a psychiatric issue (although who wouldn't be driven insane by being locked up in a hospital room for days?) or a pressing physical complaint? (I don't imagine a leg ulcer infested with maggots* can be purified without any amount of pain).

But, unfortunately... well, unfortunate for those people who find themselves confined to hospitals, and also for those people like me who have the option of working in one... the worst thing about hospitals isn't the patients or their illnesses. The worst thing about hospitals are their dumb-@$% rules.

I have a patient. He is my only patient. He is my favorite patient. He is super old and he has borderline dementia.... he reminds me of my father and so I try to be super nice to him because he, like my father in about a decade, deserves the best.

One of the things that is really hard to deal with while working as a pretend internist is how old and close to death so many of our patients are. In surgery, all of our patients had to be surgical candidates, and to be a surgical candidate you have to be able to withstand general anesthesia and someone poking around your insides. This is not so with internal medicine. Hell... one of our team's patients died the other day.

SIDE NOTE: I think surgeon's fear death way more than other physicians. While m&m's (morbidity and mortality) presentations for internal medicine (IM) are relatively tame and emotionally controlled, surgery m&m's seem to be intensely discussed, with the accusations of "who-to-blame" are hotly debated. I think this is a result of surgeon's wanting to, one some level, think of themselves as able to prevent death in their patients. I think this also makes much more timid, surprisingly, when it comes to patient care. I called both of my parents today (remember: both of my parents are surgeons) to ask them what they would have done with one of our patients: patient is an 84 year old man, with a past medical history significant for hypertension, diabetes, and two previous strokes, who was admitted to the hospital 7 days ago with slurred speech and left sided facial weakness suggestive of acute, focal cerebral ischemia, with brain CT and MRI also suggesting stroke, who know, the day before being cleared for discharge, has spiked a WBC count. Both of my parents said he should stay in the hospital. True, you should find the source of his infection. But we could almost be sure what the infection was... couldn't we just treat him for that and send him on his way? The extra care my parents seemed willing to offer might have simply been an artifact from how much more surgeons have to pay in medical malpractice. OR, they could simply hate seeing patients die from something so insidious and so simple as an infection. 

Where was I...? Yes, the incredibly stupid rules. And I'm not complaining about stupid seeming rules that are set up for the purpose of patient safety. For example, this patient, with his borderline dementia, was put on high fall precautions... essentially, he was strapped to his bed by soft handcuffs, which are called "soft restraints" in medical jargon. I understand this rule--if he falls out of bed he could easily die--although it is terrifying to think of fading in and out of orientation to a world in which you are permanently tied up against your will. No. I hate rules like the one that requires the next of kin to physically enter the hospital to sign cover-your-ass paperwork when the patient isn't at full decisional capacity. And even though a lot of terrible malpractice cases, a lot of morbidity, and a lot of mortality have arisen from the fact that things weren't explained well enough to the patient, there are some procedures that are so non-lethal it really doesn't make sense to require the patient's family member(s) to come in. Some people are busy. Most people are busy. Even I never get a weekday off work... if I was told I had to go to the hospital on a Wednesday to fill something out so that my parents could get discharged... I'd probably still take until the weekend to scrounge up enough time to liberate my parents. Doctors know what's best for the patient. We shouldn't have to explain to the patient how the procedure is done, what risks are involved... if the risks are minimal enough.

I know, I know: that wreaks of paternalism. But in all honesty, what we do now is highly inefficient. If I become an internal medicine resident, I'm going to spend my intern year writing down all the times money and/or time was wasted because we had to get paperwork down before patients could get what they needed and leave the hospital as soon as possible. Some patients love staying in the hospital... most patients don't. All doctors want to see their patients get back to baseline so that they can be discharged. But I don't think enough doctors want to put in the time necessary for analyzing why these rules and regulations are often detrimental.

Or maybe we just don't have the time. After all, I rarely see doctors taking off weekdays.

*yes. there were actual maggots in this patient's room. there were actual maggots under her skin. however, when they were finally discovered and the wound care nurse and her assistants were telling everyone outside the room about their findings within, I did not--in that moment--have enough courage to walk inside and look that hollering woman in her face while examining her wounds. I was not brave enough to examine and deduce what exact parts of her scabbed up wounds were flesh and blood and what were maggots.

So this is emergent care?

My teammate and I were sitting on the plethora of abandoned chairs in the emergency room. It was an odd time of the day for people to show up--right around lunch time--and it wasn't the right weather: too cold to be outside and accidentally or intentionally get hurt. Yet there were still patients in about half of the rooms, and because we were on call, all those patients who could be deemed fit for admission had to be processed by us. While we had been interviewing a man with suprapubic pain suspicious for bladder cancer, nearly continuous screams were emanating from a female patient nearby, drowning out the sounds of televisions, beeping monitors, and phone calls. I've been getting better and better at ignoring people screaming in hospitals. But this woman was loud and persistent and every once in a while I could hear the crashing of equipment or cheap furniture, and I'd wonder why a code hadn't been called yet or why nobody had tried to administer drugs.

I was incredibly saddened that the screaming had stopped--it is secretly my dream to rush in to help with a "Paging Dr. Strong" or "Code Grey" (combative patient/person). Alas, today was not going to be that day. Our intern had disappeared again so we had little to do except periodically check up on our patients through their electronic medical records. And then... an Emergency Medicine resident swept by and without hardly stopping asked: "You medical students?" "Yea," we both answered. "I need one of you to follow me." I started asking why as my friend was already standing up to follow him--she is way more instinctively helpful than I am. "To chaperone." Only as they were entering one of the private rooms did I kind of understand. Female patient. Delicate issues. Male doctors needed a female in the room. How obnoxious and unnecessary. So this is where politically correctness was taking us, that male doctors were no longer trusted enough to perform gyne check-ups without female supervision. 

Shortly thereafter, I was pulled away by one of the resident's on my internal medicine team to help out with ABG draws and paper work and phone calls. Eventually my teammate pages me.

"Hi Elora. It's Rebecca. Where are you?"

"The residence room. Why?"

"Okay. I need to tell you something. Will you be in the residence room for long?"

I looked at my computer screen, at the list of patients who were awaiting results of labs and imaging.

"Yea I'll be here."

to be continued. 

Internal Medicine Clerkship (Entry 1: First Impression)

So now I'm starting the third week of my internal medicine rotation, and I am loving it. These residents are significantly nicer than the surgery ones (although most of the surgery residents were definitely good human beings), and because of that, I feel like I'm getting more out of the rotation. Basically, I feel forced to learn and study on my own because not looking something up would make my residents disappointed in me and that would break my heart.
Speaking of hearts, and as an example of the previous statement made above, I finally understand EKGs. It's still very difficult for me to determine what the exact diagnosis is, but considering before I could only get rate, I think it's a step in the right direction. Maybe by the end of this rotation I'll feel and sound intelligent! The only drawback--but it's not that bad--is there's a lot of scut work. A lot of using pagers and calling people and talking to nurses, or social workers, or consultation services.
Speaking of scut work, today I was trying to decipher a note, but it was using an abbreviation I didn't know so I sent an e-mail to my surgeon dad to see if he knew what it was (I could of more easily used dr. google, but I like to keep my dad informed of my learning).

ELORA: "Hey dad! Does PCI stand for percutaneous catheter intervention? Thanks!"
FATHER: "I am not sure. That is why acronyms are not welcome in medical practice. It does make sense that PCI stands for percutaneous catheter insertion. It could also stand for pulmonary catheter insertion or pulsatile cardiac imaging. The message is TRY NOT TO USE ACRONYMS unless you are with friends, who cannot judge you. Dad."

Virtues in Medicine

It was a dark gray day in late summer. No rain. Just cold, northern air that had brushed across my face as I walked from the "L" train stop to the hospital. It was 5 in the morning. This was surgery. You had to come early so you could pre-round, and pre-rounding was something I didn't enjoy. But I did it anyway because talking to patients about frivolous matters was better than getting yelled at for incomplete notes. "Have you been going to the bathroom?" "Are you eating alright?" "Have you been walking?" Waking up anyone else to ask questions like this would be insane. But after you've been operated on, you hand over your rights to interesting conversations and get to be awoken at any time for a barrage of inconsequentiality. My reasoning was simple: the surgeons seem to think these questions matter a lot, so I asked them.

Then we round. I enjoy rounding because I get to cross my arms behind my back and walk around the hospital quickly and quietly with my fellow medical students, a flock of baby ducks following behind residents. It is generally peaceful. Today it wasn't. Today we went to see a patient who has some form of nasty infection in her leg. How nasty? Well, surgery residents are highly sarcastic. But if they weren't flat out lying in the residents' room during sign-out, well then... this patient could possibly die from this infection. The solution? She needed her leg amputated. Late last night, during her admission, she had signed a consent form okay-ing the procedure. Now as we saw her, she was resisting. She wasn't going to lose her leg. A soft-spoken but snarky, sixty-something year old woman--this patient was refusing the operation for some reason. As a human being I could see the resistance in her face. I knew there was more to the story.

But the resident just asked the same old, stupid, inconsequential questions. And the wall separating us, hidden underneath white coats, and the patient, sickly and exposed behind a cheap hospital gown, shot right up. The rounding team left. Notes for the intern: send the patient over to internal medicine. Get them to deal with her.

After rounding, everyone disappears into operating suites. I stayed behind on the floors. And I went back to that old lady's room. I left my white coat at the nursing station, and I went and reintroduced myself to this woman. I broke the silence with some silly, history taking questions: "What brings you in?" "Where does it hurt?" Then I asked the question that nobody had asked because nobody took the time to connect with this patient. "Why don't you want to lose your leg?" Followed shortly by, to get around the wall, "Why don't you want to lose your leg, really?"

And everything spilled out. This patient's history of present illness, but what it really was, not with transformative language but with a story anybody but these surgeons could understand: Recently widowed, fifty pack year smoking history, mismanaged diabetes, shame at being in the hospital again, too embarrassed to call her only living relative, her son, to tell him that she might be dying, because what would he say, "Mom, why didn't you listen to me? You've got to take your medicine. You've got to stop smoking."

It's regrettable nobody took the time to figure out why this woman was refusing treatment. It only took a smile, friendliness, and fifteen minutes of my time.

"You should call your son. Tell him what's going on. And you should get this surgery." I had told her. And she did both of those things. The next time I saw her she was missing a leg. But she smiled when I walked into her room to pre-round on her.

Clerkship

I hate my life.

But first, let's focus on the positives:

• During my last entry, I had decided (although not revealed) that I was going to push my step one test date back 10 days to June 11th. Good news, I passed. 
• I am now almost entirely moved into my downtown apartment. My room is still full of random stuff and I still don't have a well stocked fridge, but I know the area pretty well now and every weekend I go to the beach (within walking distance) with my friends. 

Okay, now on to clerkships.

I started with Surgery. At Lutheran. Widely rumored to be the toughest place to do a surgery rotation. Results are in: I hate it even though I love how much I'm learning and how much I'm doing everyday. In the last two-and-a-half weeks I have cried six times, every single time because of surgery. I am a mess. And I finally know exactly why so I'll tell you:

Being a third year medical student on rotations is like being a middle child: no one likes you and no one pays attention to you so you might as well die. 

If we were to compare the classical hierarchy of teaching hospitals to a nuclear American family circa 1950, the Attendings would be your parents, your older sibling is the residents, medical students are the middle child, and depending on group dynamics, the role of younger sibling is played by either medical students who are great at sucking up and being professional or interns. 

Attendings are the people you want to be like. They are your role models. Sometimes you hate them, but most of the time you love/respect them. They may make you upset because they yell at you and occasionally call you dumb, but eventually you realize they are right about almost everything. 

Residents are your older sibling. But there are a lot of different ways older siblings can act:

-We're in this together: Life is hard. But with any luck, your older sibling likes you and wants you to succeed. This sibling gets extra points if they know how to succeed. Residents can be good role models, just like attendings, but they can also be terrible influences. And as a young med student, you can't really know what's right or what's wrong yet. So you just pray these people are good influences.

-Too cool for you: Okay, you can't really blame someone for this, and to be honest, medical students are dorks. So...

-Constantly antagonistic: For some unknown reason, most likely being they are still bitter about that you took attention away from them (i.e., your birth), they hate you. They would never say that. But if they can, they will make you look bad. For fun. Because, to sum it all up, the world is cruel and if seeing someone else suffers helps you get through your shift, then someone's going to suffer. 

Essentially, residents will determine how you feel about yourself day after day. Your parents may be important to you, but sometimes, they just don't understand. If a resident physician tells you that you did something well, then you feel pretty cool and competent. Otherwise you're just a useless person who know one pays any attention to.

Finally, there are the suck-up med students, the little sibling who really just makes you feel worthless. Everyone is so much nicer to them for reasons you cannot completely elucidate. They are even nice to you--but only some times. At other times they are totally working the angle so they get more assignments. Everyone wants to be around them... nobody wants to be around you. 

Anyway, I'll probably post up something less... emotional, more analytical later. But right now, an hour past my bedtime, I'm genuinely shocked that I haven't quit yet. 

More good news I guess.

Thalassic

Thalassic is defined as "of or relating to the sea." Thalassemias are hematological conditions in which you don't produce adequate amounts of certain proteins that compose your hemoglobin (the stuff that carries oxygen around on your RBCs).

The name for this condition comes from the prevalence of this condition around the Mediterranean Sea, essentially: you live around a sea and your blood is messed up. However, another translation of Thalassemia would be something like.... "Blood full of the sea" or "Sea Blood" which sounds to me like the exact opposite of Land Lubber. I love it.

Unfortunately, there is a wide spectrum of how severe a thalassemia can be: from clinically silent to death in utero. 

13 days, 23 hours

I pushed back my test 10 days. I wasn't hitting what I wanted to get on my practice exams, and it didn't seem realistic that I'd get to that target in five days, no matter how much I studied. Also, I've probably spent over $1000 on books and reviews for this exam and all the courses it supposedly covers. I'd like to at least skim all the materials I have.

Oddly, my stress headache has returned. Which is impairing my ability to study. You can't overdose on Ibuprofen right? Damn it. I should know this.

HOLY .... ! IT'S ACTUALLY A TUESDAY! This update on my progressive is appropriately timed, then. And I'm taking the exam on a Tuesday. That bodes well, doesn't it? 

6 days, 20 hours

Continuing on with how poorly my body handles stress:

I've developed BPPV (benign paroxysmal positional vertigo) and the skin on my outer ear (my auricle) is peeling off and scabbing over and it is thoroughly gross.

I was going to claim that I have trichotillomania (compulsive pulling of hair) or dermatillomania (compulsive picking at skin), but apparently these are serious conditions. And even though I can't sit still and not pull my hair or pick scabs while I study, I feel absolutely fine when I get up to do something else (that's a lie. I never feel fine anymore).

Regardless, my exam is in 6 days and 20 hours. I have a box of Pop-Tarts, a box of Teddy Grahams, Hansen's natural cane soda, Fruity pebbles, and a box of Quaker Chewy bars. I also have about 65 more hours of lectures to watch. So.......

Rifampin blocks RNA Polymerase.

Okay, so I think I was being a tad melodramatic. True, this level of stress and constant cramming is incredibly dangerous to my health: I have lesions on the mucous membrane of my mouth, I bruise much more readily than ever before, I see so few people that I talk to myself and drag my teddy bear everywhere I go for companionship.
So I lied to myself. I'm going to pass step 1. Now I'm just studying. Not for a good score. Not to pass. But simply to learn. And it is fun. I'll tell you why:
There are fundamental concepts I just don't understand--never understood them--but now I have a chance to solidify the simplest things, and hopefully memorizing from this point will get easier as I develop a stronger framework.
I should have anticipated this earlier--I barely passed all my classes last year. UWorld tells me my worst subject is Physiology. Uh... what?That's not good! Physio is pretty much everything in medicine without a proper name (because pathology is actually everything in medicine, but it's just so obnoxious with all of it's diseases named after now dead jerks). So now I'm just focusing on physiology for a few more days than I originally planned. And I feel like that'll be alright.
Honestly, I just want to sound like I know what I'm taking about--even if it's just vaguely--when I step into surgery July 1st.
Speaking of....!!! I finally know the difference between prothrombim time, partial prothrombin time, and bleeding time! It was so simple I don't understand how biochemistry AND pathology overexplained it to a point where it didn't make sense. But it's probably also my fault, considering I thought plasma cells were platelets until recently. I AM DUMB.
For know...

UWorld Blues & A Murderous Rage

Studying for boards is driving me into a murderous rage. It is a combination of self-hatred for not studying more earlier and the incredible disbelief that they want us to know so much.

Also I keep getting diabetic questions wrong on UWORLD, which is probably the most depressing thing. You think you understand the process of something fully only to find there are perverted ways of asking questions that make you question what you once knew as true.

This is hell. I also have normal human being things to worry about, but I'm not paying attention to them anymore. I need to cash checks. I need to move. I need to get a new phone. I haven't checked my blood sugar in three days because I lost my glucometer while trying to pack up my apartment. So that should freak me out. But it doesn't. What makes me chuck the First Aid review book across the room as hard as possible is not the fact that my life has deteriorated to this point where I don't care about my own health and safety. No, it is the realization that I don't know how Rifampin works. I haven't been this angry since I studied carbohydrate metabolism in Biochemistry--a class I was desperately failing. I actually flipped a table when I realized memorizing all the intermediates and enzymes that metamorphose glucose was not going to be enough to do well on the exam.

That's how I feel right now. That I know a lot, but that come test day, everything I know either A) won't be tested or B) won't be enough to answer enough questions correctly.

But I have come way too far to fall apart in the next 12 days and fail Step 1 on June 1st.

12 days.

Board Review Friday

Systems. I'm going to do this by system. Or by subject. But mostly system. I'm going to get really excited and read library books, and draw multicolored pictures, and ask good questions, and find good answers on Wikipedia, about the following subjects in their following order:

1. Immunology
2. Cardiovascular
3. Respiratory
4. Peripheral Nervous System (Autonomics)
5. Anatomy
6. Endocrine
7. Reproductive
8. Liver
9. Biochemistry
10. Renal
11. Gastrointestinal
12. Central Nervous System
13. Microbiology
14. Pathology
15. Pharmacology

Just kidding. There's no way I'm going to follow any structure, whatsoever. A lot of third and fourth year students kept telling everyone: find a study system that works for you, and stick to it. I'm good on that first part. I've found many systems for studying. But I can't seem to stick to any of them. 

However, that being said, I did spend four hours in the library the other day, just reading about B cells and T cells, and it was a ton of fun. I am not being sarcastic. Thoroughly enjoyable. 

I like reading books. I like asking myself questions. And I like drawing diagrams. Hopefully by the time this is over, I will have a cute compendium of colorful notes that I can keep for years and years and share with the next generation of Apantaku's when some of them start going to medical school. And they can laugh or learn from what I will have learned in the next 42 days.

Wait. 42 days?! That's only 6 weeks! That's only one-thousand-and-eight hours. Actually, because it's 4 pm, it's only 992 hours! Terrifying. 

So if I suck at sex I won't get this?

Are You Experienced? - Jimi Hendrix (1967)

We have our sex test tomorrow! It is disgusting. I have seen a lot of penises--bleeding, ulcerated, swollen penises. Upside (OH GOD I TOTALLY DIDN'T THINK THERE WOULD BE ONE), the female genital tract is pretty fascinating. Downside, I am now worried that I'm going to get cervical cancer. Or some weird ovarian cancer (there are a lot of them and I haven't looked at those lecture notes yet).

Gender Discrepancies (I/II)

Did you know women and men are actually quite similar? We really are. If we were all raised in a society that interacted with the two genders in the exact same way, we'd probably end up like some gender-neutralized weird race of alien a la Star Trek: The Next Generation. We'd still have the two separate sexes, but we probably wouldn't have this weird, polarized, gender dichotomy. The terms tomboys and janegirls, for example, would no longer make sense and be cast aside like the frivolous trash they are.

Yesterday, in our community groups (which is basically a quarter of our class plus one practicing physician from the surrounding area), we were asked to talk about American health care. We were asked vague questions by our community leader and what ensued was kind of hilarious and also pretty depressing.

On a side note: I talked entirely way too much, which is unfortunate because I hate people who act the way I acted yesterday in class. I will have to implement a more stringent foot-in-mouth policy for any future large discussion groups. I am also a crazy liberal. I need to stop telling people I'm a moderate since I clearly believe that taxes are necessary and the government should govern our personal liberties as little as possible (but I still think we should all have access to affordable health care because it should be a personal liberty).

There were a lot of nuances in our overall debate--this is to be expected since if we could formulate a clear solution to the health care problem in an hour and a half, than our government, as crappy as it is, would already be enacting such solutions as policies nationwide. But in the end, clumping all the nuances together and then defenestrating them because who actually gives a **** about nuances?--there were only two general positions a person could have: you believe Universal Health Care should be guaranteed for everyone or you believe that Health Care should be payed for by individuals in some way outside of paying taxes.

Good points can be made for either side, but as you recall, I threw all those nuances out the window, and it seemed for the most part that the most avid supporters of the opposing sides were also of opposing genders. Universal health care is somehow more appealing to more women than it is to men.

Although clarifying point: my sample size was quite small (n=48) and it wasn't as if no men liked the idea of universal health care. Some favored it. Also, not everyone talked so the real sample size is closer to around 20. So I might just be making up a ton of crap, in which case, I'm sorry if the following is just super offensive. 

I am trying to figure out why that is. Last year when I went to the American Medical Women's Association's National Conference in Miami, the keynote speaker kept commenting on how women are dearly needed in the medical field because women are natural healers and we just care more. It was pretty inspiring but it seemed kind of hurtful to the small amount of dudes I knew who are actually pretty loving people. But now that I think about it, do I actually know any guys who are selfless? Or are they just decent human beings who have yet to have their selflessness tested? How selfless are they, really? Because I don't think caring is quite enough. I care a lot about things but don't actually do anything about it because I am selfish. I really care about making sure people understand that America's  oppressed groups aren't all good to go now that we've slapped band-aids--Title IX and Affirmative Action--on the gaping wound that is injustice. But all I actually do is update my status on Facebook, maybe including a link to a blog article or a recent study.

But when I think about selflessness more, I realize a better question may be: do I know anyone who is selfless? 
Not many.
Well, that's depressing, seeing as I am in Medical School. But I guess everyone isn't being "selfish" per se, just too busy studying so that they can one day be selfless. <<>> This seems too nuanced. I will stop ruminating. 

If we just assume women care more, why is that so? Is it because we have the capacity to become mothers? Because men have the capacity to become fathers, which I have been assured can also be a full time job. Both of my parents were full time Surgeons, and I am sure they both cared about me equally, but I saw my mom much more than I saw my dad, so can we assume my mother was more selfless than my father? I think that is a far argument. Although we will never know for sure because my dad may have thought that by working longer hours, he would be able to give us more opportunities with the money he'd make, and to him, that would seem like a more valuable pursuit than teaching us how to tie our shoes. My dad may have been selfless. Conversely, my mother may have spent more time with us to show the world that she was not only capable of being a woman and a surgeon, but also a loving mother. My mom may have been selfish.

But either way, actions speak louder than words, and I saw my mom more than I saw my dad, even though they had similar jobs. I think this behavior must be socialized, because my mom didn't actually need to spend so much time with us. We could have just had babysitters who stayed at our house longer.

 Now that I've dragged you through my own internal thought process, let me actually tell you facts: female physicians make $17,000-a-year less than male physicians, on average, for doing the exact same amount of work. This number has been normalized, so any arguments that male physicians tend to work longer hours (as was the case for my parents) or that male and female physicians choose to enter different specialties or practice in different locations (as was not the case for my parents) does not at all affect the statistic that women make $17,000 a year less than men for doing the exact same work. Discrimination, of course, plays a role in this inequality, but another interesting point that the researchers brought up was that some of the blame actually falls on women: women will stop negotiating their wages with their employers at a lower rate than their male counterparts. You could see this as women having a lower innate self-worth (which is true in society overall but may not apply to physicians) or you could see this as women willing to do more "caring" for less economic compensation. That sounds a lot like selflessness to me.

NBME: Behavioral Science

Our National Board of Medical Examiners Behavioral Science subject exam is in two-and-a-half hours. I am haphazardly reading through all our notes as quickly as possible. Our Clinical Neuroscience professor composed a powerpoint with 1,326 slides. It is a fun romp through various topics, both interesting and trite. Although some things are just entirely unexpected:

Well we were talking about Freud. 

.... Shelf!

Surprise! I have a giant subject exam next Wednesday! I'm terrified! Hence the exclamation points!

I'm terrified because it will be worth 20% of my final grade in my favorite class: Clinical Neuroscience. I had a feeling I'd like psychiatry even when I came to medical school, but it was never something I thought I'd seriously like.

I came in with a pledge to make medicine easier to understand for my patients. I fully believe I will have to see a lot of patients, but I want to make every single one of them feel in control of their health--by giving them the information and the support they need to make their own decisions.

This is why my final research project in college involved looking at the ways doctors communicate with their patients.

And psychiatry, I realize, sets itself up as the specialty that requires communication over everything else. Even with primary care--let's say family medicine, which is still my first love--you talk with the patient, and most of the time, talking is all you need. But you still approach a patient in primary care as an algorithm. History fills in some information, labs and tests fills in the rest. You shake it up, and you come up with a diagnosis. Or several diagnoses.

Psychiatry at the very start basically says: the only way you're going to get anything done is communication. There is no back up plan. You can't be that doctor who is really smart but also really distant--really bad at talking to people. I guess what I like most about psychiatry is that it really emphasizes medicine as an art form.

Regardless, I am now considering a double residency because hey--I'm young. But what I really want to do is qualify for an Honors Elective in Child Psychiatry. That was the most ... electrifying part of this course for me. Many of my friends, I realized, had these conditions. Most memorably, my best friend in elementary school had selective mutism. Which I always thought was interesting as a little kid, but now I understand it and I find it even more interesting.

Anyway, to qualify for the Honors elective I need an A in clinical neuroscience. And right now, without any extra credit, I have an 85%. SO FAR AND YET SO CLOSE. So, the next 6 days of my life will probably be panic, panic, panic.

Adding pain to misery, 50-55% of the exam is on "Central and Peripheral Nervous System" which is incredibly vague. Fortunately, the vagueness was removed by the course director who basically explained this chunk of questions as focusing on... you could easily guess it... my least favorite and, I am not exaggerating this when I say, my most personally antagonizing part of medical education... Neuroanatomy!

Trials and tribulations, right?

Here's to a weekend of staring at brains!

Full Circle

I still suck at board review tuesdays, but I seem to have developed a pattern of writing in every eight days, so expect me to write about something, I suppose, next Friday.

Although the real reason I haven't had anything to write about concerning boards is because I haven't studied. At all. For over a week. For over eight days.

I'm freaking out, but instead of doing something about it (namely, study) I seem incapable of doing anything productive.

I mean I'm studying for school, but school grades don't matter. Hah!

Eventually I'll probably get out of this slump. I can't imagine cramming for the boards. That sounds like a hell no one deserves, no matter how undisciplined, dumb, currently care free, or beautiful* that person may be.

Speaking of actual school, I'm excited for class tomorrow because our hit-or-miss pathology class will be hopefully educating the idiots in my class about what diabetes is. And honestly, I could learn some more about type 2 diabetes too. I'm sick of how much stuff we know about diabetes that isn't mine. I've been skimming tomorrow morning's notes for fun.... Wrong word... curiosity. Looks like a genetic component for type 1 diabetes has been proven in white people. Which is great for me, a curious, half-white person of child-bearing age who really wants to know if my genes are defective or if I'm just unlucky. I want, nay, need to get sequenced. Besides the diabetes I am literally perfect**.

Fortunately there is at least one amazing thing about the lecture notes for tomorrow:

Borg Picard in a diabetes lecture?! 

DAMN! I'm watching television (I was not kidding, I am a failure) and I just heard Lucy Liu say the word "neutrophil." Apparently she's an ex-doctor on the television show Elementary. I approve. And I am feeling pretty lucky. Maybe I will study tomorrow.

*I needed a pick-me-up.

**I still needed a pick-me-up.

Occupational Diseases (Hypersensitivity Type III Reactions)

"There are many...pulmonary type III reactions that bear names related to the occupation...such as pigeon breeder's disease, cheese washer's disease, bagassosis (bagasse refers to sugarcane fiber), mapke bark stripper's disease, paprika worker's disease, and the increasingly rare thatched roof worker's lung." -Immunology: A Short Course, 4th ed. Benjamini, Coico, and Sunshine. 2000.

God I Suck at This (Board Review Tuesday)

So I missed Board Review Tuesday again. Maybe I should call it Board Review Wednesday and cut my losses.

Panic set in for the first time over my spring break (last week). This was probably due to a few of my classmates posting up pictures of the library to Facebook whilst complaining about how much they were studying.

I still am not 100% sure of how exactly I am going to study for boards, but I have an idea: I will write my own notes for each system of the body. System based learning done the right way because it will be personalized to me.

To start off each section, I would re-familiarize myself with anatomy and physiology of the system. Then I would discuss pathology, including microbiology and immunology if relevant to a specific condition. Finally, I would end with pharmacology and other treatments for the condition.

Hey! This could actually work! Of course, that's what I said about CramFighter, and I'm not really using it anymore.

I mentioned this to a friend--and it seemed like one of the truer things I have ever said--but essentially, the inexplicable feeling of doom that accompanies pancreatic cancer is exactly how I feel about boards. I'm not sure exactly what's wrong, I'm not exactly sure what I should fix: all I know is that I am screwed.

Advice from the Downeaster

Last week was our spring break (conveniently located in winter), and I spent some time in New York City before heading up to Maine to visit my older, lawyer sister. The Amtrak Downeaster travels between Boston and Brunswick, the largest town (not city, which would be Portland) in Maine with a population of over 20,000.

Regardless, I sat down next to a window, minding my own business, when an incredibly chatty older woman, her friend, and her friend's daughter, sat down in my row. I tried to quietly play Triple Town on my tablet, but I could not escape the questions and story tellings of the woman, and we eventually fell into an on-again, off-again conversation that eventually ended in me getting a free Shipyard Export Ale.

Thankfully for me, the woman was a retired nurse anesthetist, and therefore our conversation was a lot more interesting than the conversations I've had with other people I know nothing about. Pathologies and other medically related topics that came up in our conversation included the following:

• Neurofibromatosis Type I & Type II
• Renal Cell Carcinoma (RCC)
• Abdominal Aortic Aneurysm (AAA)
• Celiac's Disease
• Out of Sync Child
• Dyslipidemia
• Migraines
• Alcoholism
• Disseminated Intravascular Coagulopathy (DIC)
• Metastic Breast Cancer
• Bone Spurs
• Vaginal Birth after Cesarean (VBAC)

Incredibly fascinating! As it turned out, the group of three women had travelled down to Boston to get a better opinion on an AAA found in the friend. Originally, the AAA had been sized as a 4.7, but in Boston--with better equipment--it was sized at 4.2. And oddly! I knew exactly what that meant! 4.2 is in a lower risk group than 4.7. And so to celebrate, they had all gotten drinks and were still in a pretty joyous mood. Which is why, an hour away from Brunswick, this woman got herself a gin and tonic while also getting me a Shipyard (which is a delicious microbrew). 

Anyway, before leaving the train, she made sure that she had given me the following two pieces of advice, several times:

• You need disability insurance more than you need life insurance--start paying into it early.
• Keep a journal and write down the quirky/fascinating little stories that are part of your day to day life.

The first piece of advice was given to me because of the woman's personal experience: she had been a nurse anesthetist for a long time when she was injured on the job (broke her hand due to faulty hospital equipment), and found it impossible to keep going to work. Without disability insurance, her family would have struggled. A stark reminder of how important working mothers can be to their families.

And it was obvious why the latter one was pertinent--this woman had decades of really interesting stories to tell, ranging from the depressing and upsetting, to the hilariously unbelievable. I hope that this blog will function as a repository for the brief encounters in my day to day life as a healthcare professional, holding onto stories until one day I too can expound upon them with a much younger person I've capriciously decided to mentor on a three hour train trip.

Meanwhile! I love Portland, Maine. It is beautiful. It is cool. It has nice restaurants. It has nice beers. It has a lot of gay pride. It is nerdy. It is liberal. It is walkable. And it has a hospital in it! I kind of want to try and spend a part of my fourth year rotating through Maine Medical.