Specialties

After I gather all my thoughts, I'll write a more comprehensive post on what specialty I may pursue (after all, it is the most popular question at family gatherings over winter break). But for now, I wanted to write a bit about internal medicine.

Internal medicine was always a strong consideration for me. I love the diversity of cases, the problem solving, the intellectual nature, and the sheer excitement of diagnosis. It's fun. I could make a career of hunting zebras, and internal medicine may be the path to pursue that. I get along well with the medicine personality and mentality. I think I could be good at it. But there are many things I don't like about internal medicine. So many people go into it; it's common. I don't mind doing the same thing as others, but in considering a career in academia, making a niche in internal medicine is much harder than finding one in another specialty. Many people lament the poor reimbursement in internal medicine. While that's not a priority for me, it's something to think about.

Of course, there is a wide array of internal medicine subspecialties. Cardiology has always appealed to me because the heart is so fascinating. While ischemic heart disease and interventional cardiology doesn't draw me, I could easily see myself going into cardiac electrophysiology. Gastroenterology and pulmonology involve bodily fluids so they're out. I don't know enough about nephrology or hepatology. Endocrine and rheumatology are exciting specialties because they're not organ based; they offer a lot of diagnosis, zebras to manage, and problem solving. I really like hematology but I don't like medical oncology (at some point, I'll blog about my LCE heme/onc clinic). Infectious disease always interested me but I'm not sure if I'd pursue the training. I always thought I'd want to work with critical care patients, but I'm not sold on it yet.

Medicine 110

I had a great time in my medicine rotation. It went by incredibly quickly, and at the end, I felt that there was still a lot to learn. Coming off of surgery, I found medicine to be flexible; I had so much time to read UpToDate, to attend case conferences, and to get to know my patients. Moffitt was a fun hospital for me. The cases I saw were complicated, unsolved, and rare. I definitely did not get the ideal caseload for a third year clerkship, but I didn't mind. I never saw some of the bread and butter we were supposed to learn; I never took care of a garden variety pneumonia or COPD exacerbation or asthma attack. Instead, I learned about cystic fibrosis with multiple complications. It was fun; I loved it. I think the clerkship objectives are too basic anyway, and I learn all the fundamental things as I try to tease out the complexities of my patients.

I loved my teams. My residents and interns were by far the best I had worked with. They really appreciated medical students and understood our roles and responsibilities. The attendings all had their particular niche; I worked with experts in cardiac stress testing, end of life care, patient satisfaction, and AIDS. That was really educational since their passion for their particular field of interest inspired them to teach well.

So far, medicine has been my most enjoyable rotation. I went in thinking I'd like it and I wasn't disappointed. The focus on medical student teaching was a highlight of the rotation and I was well treated by all members of the team. I learned a lot from my patients and contributed positively to their care. I think I could have had more independence and taken more patients, but that will come in time.

Poem: Abacus

Abacus

Fingers fly across the paper,
the sussuration of thumb and index
conjuring wooden beads in my mind
like a phantom rosary
from the days of meditation and meandering,
a time without numbers save infinity
when succor was measured in clasped hands,
digits, intertwined, restless.

Passion casts aside its many masks,
warrior and widow, grave and graver
like cracking an egg and letting
the yolk fall through the sieve of fingers.
No, it’s better this way, we say
over the pinprick of a candle
a nub in a pool of wax, smoldering
in favor of a little electricity.

Work Hours II

So then, what is the solution? We want our doctors to be well rested, thinking clearly, and wary of mistakes, but we also want our doctors to be ours, not a succession of hand-offs between providers we've never met. I would suggest decreasing the number of patients each team takes. With fewer patients, the interns can focus more attention on fewer people, delivering better care. There's more likelihood that an intern can get some sleep on call without introducing more hand-offs.

The question is how to accommodate the same number of patients if each team has a lower cap (maximum number of patients admitted each call night). At Moffitt, the only admitting services separate from medicine are cardiology and a cancer research institute service for "liquid tumors." So we take a lot of "chemotherapy babysits" for solid cancers. When a patient with a diagnosed cancer needs inpatient chemotherapy, they get admitted to medicine for housekeeping while oncology writes all the chemotherapy orders. These patients are of low educational value since the primary medicine team does very little in their management. I think introducing a separate chemotherapy service run by oncology reduces the number of patients admitted to medicine without substantially increasing work for oncology.

Work Hours I

In 1984, the inadvertent death of Libby Zion at New York Hospital caused the public to put pressure on hospitals to restrict resident work hours. She died of serotonin syndrome from an interaction between meperidine and phenelzine, and it was determined that her death was due to long unsupervised resident work hours.

In 2003 the ACGME, a governing body that accredits training programs, limited resident work hours to 80 hours a week with no shifts longer than 30 hours. There was no evidence for this decision; the parameters of the restrictions were "made up" in an attempt to preserve the nature of medical training and appease the public. Research has not shown that restricting work hours improves hospital outcomes or decreases mistakes. But intuitively, we think it helps. How clearly and quickly can one think, working at their 30th hour straight? Should someone that sleep-deprived have the charge and responsibility of patient lives? Recently, the Institute of Medicine put out another report suggesting that residents take an uninterrupted 5 hour nap in a shift longer than 24 hours.

Now that I've worked in an inpatient setting for 8 months, I wanted to reflect a little on work hour restrictions. I'm torn in how I feel about them. I recognize their utility; I know what it's like to be on for over 24 hours; thinking, reflexes, motivation, and clarity are obscured. But introducing work-hour restrictions comes at a large cost.

The main cost everyone talks about is hand-offs, when information is passed from provider to provider. UCSF has worked incredibly hard to improve this process and prevent critical information from being lost. Indeed, nurses do it incredibly well. But I've seen a lot of problems come about because information was not transferred properly from an exhausted outgoing team to a naive incoming day float (a resident who takes care of the patients while the on-call team sleeps). The post-call day is when the most happens for patients admitted overnight. The important decisions are made, the family meetings are held, the consults are called. Instead of the provider who knows the patient best, a day float has to manage these important decisions. Some are anticipated by the team, some are fielded by the attending, but most are simply deferred another day until the team gets back. I feel that some continuity of care is lost at this critical junction.

I also think that there's a strong educational value in longer work hours. The old school thought is that you work until the work is done, that patient care is paramount, and that there is a pride in finishing everything you start. Surgeons really have this belief. But the general feeling is swaying away from this idea with introduction of shift work in emergency departments and intensive care units. I like the old school mentality about medicine. I don't know whether it's justifiable, practical, or better, but I don't feel that inpatient medicine is or should ever be a 9-to-5 job. I learn an incredible amount on call and staying through the post-call day. That's when all the good stuff happens. I love hearing about all the new admissions each post-call morning because that's when a lot of the medicine thinking happens. But we're always rushed, racing to get out of the hospital. I would hate to be forced to go home without seeing the resolution of my patients. But I'm still a student and perhaps still too idealistic.

Pharmacy Students

Medicine was the first rotation I had which also had pharmacy students on our team. It was really fun. Pharmacists play a huge role in patient care, especially in transitions of care between outpatient and inpatient settings with medication reconciliation and patient education. They do so much work in tracking down pharmacies, following inpatient antibiotics, and thinking about drug interactions. They also do a lot of things I never think about like figuring out insurance and what drugs the patient can leave with. I learned a whole lot about meds from our pharmacist. It was also fun to have another student around.

Happy Holidays

To: You.
From: Me.

Charting

If I were to develop medical charts, I would have a separate section for family history, social history, and immunizations and health care maintenance. Data can be filed neatly in that designated area rather than under a section in the full history and physical exam. Family and social history change very little and do not need constant updating. But from time to time, they become fundamentally important, and you never seem to be able to find the information when you need it.

For example, take a frequent flier to the emergency department who has chartomegaly. Every time he's admitted, the team does a cursory family history and writes something useless on the note. After all, no one takes a good family history anymore; only medical students and geneticists have time to sit down and draw trees and ask how old each family member was with each diagnosis. So people just end up re-doing and re-documenting bad work.

Instead, start a family history section in the chart. After each visit, you can add new information, if any, to that section. You would not have to feel obligated to take and do a bad FHx; if you don't think it's relevant to the visit, you can be confident it would be similar to the one already documented. Once in a while, someone may take a thorough family history and it'll be easy to find. No more flipping through charts looking for that "one note that was so good."

Charts already attempt to do this with allergies, medications, and problem lists. Those fail terribly, but the reason is simple. Allergies are so important that everyone has to ask each visit; no one would just rely on a chart allergy (though having it documented may prompt a provider to ask specifically). Medications and problem lists change too much; no one has the time to update the list diligently and as a result, no one trusts that such lists are updated. But I think that family history, social history, and health care maintenance can benefit greatly from being documented in a separate section in the chart.

Poem: Ménage a Trois

I've been a little derelict in my poems. Here's a new one.
-
Ménage a Trois

If I loved you
fifty years ago at the altar
or on that snowy February night eight years past
I mean it no less today
as I wet your lips with moist swabs
and read the paper waiting for you to make the obituary.
This morning, Martha brought the blanket
we used, neighbors and lovers, to cover you
in every permutation imaginable.
She stayed three hours by your yellow body
before meeting the lawyer
to discuss discarding your things.
Me, I’m at the solstice of this five decade vigil
and though Martha may take your body home
I will not be far behind.

Medical Mystery II

An incarcerated man in his 30s comes to us from a prison hospital for work-up of intractable nausea, vomiting, and abdominal pain. He's had gastrointestinal symptoms from childhood, but they worsened in the last 4 years. Since then, he's had periodic episodes of severe nausea, vomiting, and abdominal pain requiring multiple hospitalizations. He's been diagnosed with gastroparesis, peptic and duodenal ulcers, and Mallory-Weiss tears. His symptoms have been so severe in the past that he's required two jejunostomy tubes for feeding. At an outside hospital, he had hematemesis and melena, and when he was hemodynamically stable, he was transferred to us because he was unable to eat. He presented to us with excruciating mid-epigastric and RUQ pain radiating to the back, worse with vomiting, minimally relieved by opiates, no identifiable triggers (no relation to meals). His past medical history is otherwise unremarkable. He takes some opiates for pain at baseline and a PPI but has no other medications. His family history is significant for gastroparesis in a grandparent secondary to diabetes, but otherwise negative. He has been incarcerated for several years now at a maximum security prison. He does not have a history of alcohol, drinking, or IV drug use. He is afebrile, BP in the 100s/60s but otherwise vital signs stable. To me, on presentation he looked almost like a surgical acute abdomen; he was rigid, legs drawn up, visibly distressed, exquisitely tender to palpation. He actually spent a night in the ICU for pain control.

Now, the obvious differential would be an acute abdomen (peritonitis, appy, perforated ulcer) vs. peptic ulcer, pancreatitis, cholecystitis, hepatitis. But his labs came back stone cold normal. No leukocytosis, normal chemistries, amylase, lipase, LFTs. They were normal at the outside hospital too. A CT of the abdomen and pelvis was completely unremarkable. A RUQ ultrasound showed no gallstones. A CXR was normal. A urinalysis was benign. EKG showed sinus bradycardia with a first degree heart block.

A medical mystery! I was excited (even though I'm not usually crazy about GI). I started with the obvious, calling in a GI consult. They did an EGD (upper endoscopy) which showed a normal esophagus, normal GE junction, mild gastritis, and mild duodenitis, no ulcers. This could not explain his symptoms. He was in unbelievable pain, requiring sky-high doses of narcotics each night.

My attending then did something quite smart and laudable. This patient was taking up a lot of resources. Over the last four years, he was hospitalized many times to no avail. Finally, he had made it to a tertiary care center. We had an obligation to rule out as many esoteric things as we could and hopefully make a diagnosis. It would not be enough simply to control him symptomatically and send him back to prison. So the attending asked me to compile the most thorough, comprehensive list of causes of abdominal pain, nausea, and vomiting that I could imagine. My assessment and plan for that progress note was ridiculous; it was 4 pages long. It pretty much included everything but ectopic pregnancy and salpingitis.

There's an interesting socio-economics question here. An inmate, this man's health care was paid for by taxpayer dollars. Is it fair to us to be paying for an extensive workup of this patient's symptoms? He's getting better health care than law-abiding citizens. Is that fair? To me, the answer is simple. As part of his medical team, he is my patient and I am his advocate. After many hospitalizations at other places without an answer, he deserved at least a decent attempt to decipher his problem.

The patient was HIV negative, RPR non-reactive, tissue transglutaminase and gliadin antibodies negative. His sedimentation rate was low, ANA negative, C4 normal. A work-up for acute intermittent porphyria was negative. A nuclear medicine gastric emptying study showed mildly delayed gastric emptying for liquids but not solids, but this was done on high dose opiates. A blood lead level was negative. A CT head showed no acute intracranial process.

Of course, the question of secondary gain arose. Pain and nausea are highly subjective symptoms (the patient did vomit a few times in hospital though). While he was in the hospital, he got his own room, had a flat screen TV, and enjoyed better food (he was soon able to take a soft gastroparietic diet) than at the prison. But the team and I spent a lot of time with him. I got to know him well, and my assessment was that secondary gain was highly unlikely.

The next day, I went to a medical student lecture on adrenal insufficiency, which can often present with nausea, vomiting, abdominal pain. The patient did not have electrolyte abnormalities but was receiving IV fluids. He was not overtly hypotensive, but he ran low pressures normally. A 4:45AM cortisol was 1 (not an ideal time for measurement, but low, especially if he was acutely in pain). An 8:50AM cortisol was 4. A high dose cosyntropin stim test went from 1 to 9 to 13. His ACTH was low normal at 9 and 15. Interestingly, a brain MR was done showing a possible old hemorrhage into the pituitary; no masses were identified. Dexamethasone made a stunning improvement in the patient's symptoms (moreso than expected in a normal person).

GI consult service could not identify a cause of this patient's symptoms and felt adrenal insufficiency was worth pursuing. Otherwise, they suggested a garbage diagnosis: nonulcer dyspepsia with visceral hypersensitivity. Unfortunately, when we called endocrine consult, they were not impressed for whatever reason.

At the time of this post, a final diagnosis has not been made. We're hard pressed to convince endocrine. However, in my mind, adrenal insufficiency could easily be the diagnosis. One thing to remember is that as common diseases are ruled out, the uncommon diseases increase in likelihood. At the beginning, pancreatitis, cholecystitis, hepatitis, ulcer disease, and gastritis probably added to 80% likelihood. But once we convinced ourselves those weren't right, oddballs like Familial Mediterranean Fever, abdominal migraine, and indeed, adrenal insufficiency have to increase in likelihood. I think the consult services lose sight of that since they worry only about their domain of diseases. But after labs and imaging suggest against GI causes, I think other organ systems causing GI symptoms should be taken more seriously.

EKG

I love reading EKG's. I think it's incredibly fun. The basics are easy to grasp; a beginner can at least make some comments on a given EKG. But there's also a beautiful complexity to it, that with finessed experience and more care, one can decipher so much about the anatomy, physiology, and pathophysiology of a person's heart. For a simple non-invasive test, it harbors remarkable potential.

Image is in the public domain, from Wikipedia.

The Gunner

Along the lines of the last post, third year is different than the other years in that the rotations are not simply pass/fail but honors/pass/fail. For a lot of students, this is a source of anxiety. We're competing with our classmates in what seems (from this perspective) to be a completely subjective and arbitrary competition. Everyone has different patients, residents, attendings. How can there be any sort of standard or consistency in evaluation? Over the span of 8 weeks, what really differentiates a "pass" student from an "honors" student? We can do our very best and simply manage a "pass," and to some, this feels unfair. The number of honors that can be given is capped, and in a rotation with 4 students, only 1 gets the coveted grade. Although we all get written evaluations, medical students are so focused on the grade that it's the root of our new onset generalized anxiety disorder or obsessive compulsions.

Interestingly, looking at the statistics, more people get honors in more than half the rotations than do people who get honors in a third to a half of rotations (I realize that sentence is confusing). This suggests that the distribution of honors is not bell-curved, and that instead, a minority of individuals get a majority of honors, thus depleting the number of honors available for you and I (I assume that you aren't one of those straight-honors-students since you're procrastinating by reading this blog).

In any case, we all dread the presence of a "gunner" on our rotation, a classmate who strives to make him or herself look good at the expense of the other students. I've heard scary stories, from people pre-rounding on other students' patients to students presenting topics they knew their peers had prepared. It's bad. Personally, I haven't come across any terrible circumstances (and I hope I'm not inadvertently causing any). The truth is, it's annoying to think of these rotations as a competition because certainly medicine is not. From my rotations so far, I realize the importance of collegiality, of helping others, of making others look good, and of appreciating peers for doing the same for you. There's enough learning and patient care to go around, and as long as I have that, I'll pass on the honors.

MS3 Isolation

There is a definite sense of isolation in the third year. We are scattered among different rotations at numerous sites, and even within a single rotation, we are assigned to many different teams. The dynamic between classmates really changes. My close friends are doing completely different rotations in different hospitals and I seldom see them, except for the rare review session or extracurricular event. After the camaraderie built in the first two years of pass-fail classes, this dispersion is sudden and surprising. We're really on our own; our expectations are the yard-stick by which we judge ourselves because no one else is going through the same experience. We're at the bottom of the totem pole, and our support system throughout all the classroom years has vanished. Where are the people I usually rant to? Who can I ask where the nearest bathroom is? Am I learning as much as everyone else?

Though in many ways distressing, I also like the independence. It feels more like work than school, an apprenticeship in an environment where friends would be nice but aren't necessary. Probably more growth happens when we have to find our way on our own. When I see and talk to my friends, it's fascinating to listen to their trials and tribulations, passions, unbelievable stories, and incredible intellectual and personal growth. It's nice to think that perhaps the same is happening to me.

Home Visit

One of our assignments was to do a home visit to learn a little bit about the discharge process and transitions in care from an acute hospital setting to the outpatient setting. We went in groups of two medical students and a pharmacy student to see how a patient was doing after leaving the hospital, reconcile medications, and assess the home living situation. We visited one of my patients who was visually impaired and admitted for a pyelonephritis. It was fascinating to see how she got around the house, differentiated between medications (they were in different sized bottles with different caps), and interacted with her children. It was fun. I felt like the patient appreciated our visit and it improved her medical follow-up.

Getting to Know People

One of my patients right now is incarcerated at a maximum security prison for assault with a deadly weapon. Surprisingly, he is one of the most courteous and pleasant patients I've had. I thoroughly enjoy seeing him every morning. It's a little weird to have armed guards watching over me as I listen to his heart and lungs. But he is always cooperative and has never been a problem or threat. I really feel that he has genuine respect and appreciation for my time. We have good rapport. I know that he might have secondary gain (being out of jail, getting pain medications) but he is my patient and I strongly advocate for him despite his social situation and history.

Post-Mortem Diagnosis

I wrote a post about a week ago entitled comfort care. Interestingly enough, we made a post-mortem non-autopsy diagnosis. In a purely academic exercise, I sent off tumor markers on blood that had already been drawn. I figured that this did not put the patient in more discomfort and could be somewhat useful for the family. Of course, tumor markers should not be used to screen for or diagnose cancer. But his CA19-9, a marker classically for pancreatic cancer but also seen in other GI cancers was sky high; normal is <36, his was over a million. I think his presentation with painless jaundice in conjunction with this lab value convinces me that he had pancreatic cancer. Putting him on comfort care was the right thing to do; there was nothing we could have done.

Bereft of Time

Recently, I have been bereft of time. Our service is very very busy right now and my current patient is a medical mystery (perhaps a future post about him once we learn more). They've been packing in lectures, and I gave a presentation today on pancytopenia (believe it or not, there isn't a direct UpToDate article on pancytopenia so I actually troved the library). I've been feeling a little sick lately, I'm really behind on some extracurricular stuff, I've been stressed about our exam next week. I'm scrambling for time and neglecting the blog to some degree. But hopefully I will remedy that as I get everything reined in.

Causes of Death

http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html

This is an excellent website by the CDC which allows you to look up the top 20 causes of death parsed by age group, state, and race. It's a good way to focus health care priorities.

Medical Student Burnout

Recently, the idea of medical student burnout has made the lay press. A few articles in the New York Times and other places allude to the fact that medical school is tough. The hours, the emotional impact, the hierarchical hazing, the overwhelming amount of information, and the intimidating responsibility all contribute to poor self esteem, unhappiness, and the wish that we had picked a different career. Some studies cite a suicidal ideation rate of 10%. It's quite scary, and I think that it's not far from the truth. There are times when I feel stressed, depressed, anxious, under-appreciated, alone. I've had moments when I've wondered about choosing this path and played the "sunk cost" economics game of whether it's too late to cut my losses and go practice law or something.

But in reflecting on this, I don't think my experience has been that bad. In general, I'm having a great time. On the previous call night, I felt exhilarated by the intellectual excitement my patients generated and though I was up at 2 in the morning, I was happy. A nap, a presention to the attending, then back to sleep. It killed my Saturday, but honestly I didn't mind. It's something more than work, this commitment that I've made to my patients to take care of them, this commitment I've made to myself to learn. I could get an extra hour of sleep every morning, but resident report is really fun, and I'm happy waking early to go. I haven't even turned to coffee yet.

It's true that there were rough times, especially in rotations I didn't particularly enjoy. I am looking forward to winter break. I wouldn't mind an extra day off or two. But when I'm at work, I can't complain. I feel appreciated by my team, I advocate for my patients, I am eager to learn. I think my personality was made to be a student. Or perhaps I haven't realized yet how much easier it is to put away that cap and gown.

Poem: Three Dog Town

Three Dog Town

I said I loved you the morning we walked through
that three dog town, past the frayed candy color doors,
along the voluptuous mountains. You arose
from the fog, the mist a shawl on your shoulders,
you asked me the difference between Schubert
and Schumann. At the time, what I said didn’t matter,
but now I admit I don’t know, I never played the piano,
never went to the operas you thought I loved.
Now walking alone, capitulation a cane, a cat of mist
winding her tail and skirting under abandoned cars.

HIV

I wanted to write a post on one of our more complicated patients whose medical course is way too complex for me to comprehend (details changed for HIPAA reasons). This is a woman in her 50s with a congenital condition causing developmental delay who was admitted with a simple infection but became profoundly ill with seizures, a-fib with RVR, a PE, and a prolonged ICU stay. Her mental status declined rapidly without a clear cause and the work-up baffled us for a long time. A month after admission, someone sent an HIV test, and she came back positive. The CD4+ count was incredibly low, and this completely changed everything. We now think she has multiple opportunistic infections in her brain: varicella-zoster-virus encephalitis and/or ventriculitis, mycobacterium avium intracellulare, a possible bacterial meningitis, a suspicion of CNS lymphoma, a question of JC virus. Her outcome is dismal, and she's likely to die of these diseases.

I was struck by how late and fundamentally important the discovery of AIDS was in this case. The sad truth is that the patient went to the wrong hospital. If she had gone to SF General Hospital, she would have been routinely screened for HIV. The American College of Physicians recommendations now are to screen all patients over 13 for HIV. I don't know if I agree with this as a general rule, but here it would have helped immensely. The truth is, if we had known earlier, it probably would not have changed the outcome. But to be floundering because we did not consider HIV - even in an older developmentally delayed debilitated single woman - is our fault.

Pebble Beach

This is a picture I took over Thanksgiving when some friends and I went down to Pebble Beach.

Comfort Care

The last patient I admitted was a gentleman with multiple acute medical problems without a diagnosis. However, looking at the clinical picture, laboratory data, and imaging, his prognosis is likely very poor. Without aggressive intervention, he is unlikely to survive. However, he and his family members have expressed a long-standing wish not to have a prolonged technological death. Time and time again, while healthy and while sick, he has told his family that he does not want to be on a machine, does not want interventions to extend life, and he wants to pass when that time comes. As a result, even without a diagnosis and even with the possibility of a reversible problem, we decided to transition him to comfort care. We felt that whatever disease he had, an invasive procedure would be necessary and since that was not consistent with his goals of care, it is time for us to relinquish our control and let nature take its course.

While I have had patients die in the past, this is the first time that I've decided to let a patient without a firm diagnosis and with potential reversibility go. It's tough. But I'm completely convinced that this is the right thing to do. The family is completely unified in supporting this decision and his values seem to persist over a long period of time. Most likely, he has a terminal illness and palliative care is on board with this course of action. I guess the lesson I learned here was reinforcement of end of life decision making and the fact that the right course of action may not be the most medically satisfying.

The Pan-Consult

One of the things I've noticed about medicine (perhaps unique to Moffitt) is the pan-consult. For many of our patients, the medical issues are so complex that we have to get experts involved in every aspect of the care. As a result, medicine acts as a hub, getting suggestions from pulmonary or neurology or dermatology or infectious disease or hematology/oncology. In some ways, this leads to more learning as we get to see how specialists approach complex disease states. However, it also leads to less independence in the management of our patients which can be disappointing. It's an interesting aspect of general internist medicine that I had not realized until now.

Poem: Bad Poem

When I took Introduction to the Creative Writing Minor at Stanford, my instructor Adam Johnson (Parasites Like Us) had us write and share the "worst poem we could possibly come up with." The intention, of course, was to make us comfortable with sharing our writing. After all, if our classmates had heard the worst poem we could compose, nothing could embarrass us for the rest of the quarter. Here is mine.

Bad Poem

I pine, sublime, whenever appears to me
such beauty as alpha-ketoglutarase.
Oh! for such a benevolent carbonyl-laden molecule
I could not speak higher praise.
Her visage appears before me
on a cell phone. But if such an apparatus
were inadvertently defenestrated,
I could find her in my very own cells,
beautiful and lovely and being slowly, slowly metabolized.
Yes, she is a scarlet woman. Look at her!
Her aldehyde is showing! How risque
to bare such electrophilia.
That scandalosity should be masked
with a methyl group, covered
like less divine saccharide derivatives:
oxaloacetate, galactose, even beta-D-fructopyranose.
Not lactose, however. I am lactose intolerant.

Thanksgiving 2008

A few of my closest college friends got together for Thanksgiving this year, and it was the most fun I've had in a long time. I was lucky enough to get three days off, and I opted for playing rather than resting. We did an amazing amount in the last couple days: walking on the beach at Carmel, chopping open a giant pumpkin, mushroom hunting along Pebble Beach, gingerbread house making, an elaborate Thanksgiving dinner, late-night conversations. I was a little worried about hosting a handful of friends during this busy rotation, but I loved every moment.

Every year, I contemplate the things I am grateful for, often very particular and personal aspects of my life. This year, Thanksgiving Grace is in honor of the soldiers, airmen, servicemen, and women in America and abroad who may not be able to celebrate Thanksgiving with their friends and family, who may be far removed from the people they cherish, who sacrifice much to protect those values of our nation. I hope for a swift and safe return of those stalwart defenders watching over us. Itadakimasu.

Cocktail Parties

"Now that you're moving into your clinical years, you'll start getting asked all these medical questions at cocktail parties. It's amazing how many people have 'friends' with genital herpes and premature ejaculation." - Don Ganem, Lecture 6/23/08.

"A few years after I was diagnosed with cancer, I was also diagnosed with anorexia...as if I didn't have enough on my plate." - from another lecture, 6/23/08.

Thanksgiving

I hope everyone has a lovely Thanksgiving. One of the things I am thankful for has to do with a patient of mine. This is an older gentleman with cancer who has been having intractable headaches. Every day when I see him, he's clutching his head in pain, feeling like his "eyes are going to pop out." He strikes me as the type of person who wouldn't complain about something trivial. Massive doses of narcotics (24mg PO dilaudid and 24mg IV dilaudid over one 24 hour period) were not relieving the pain. I tried really hard to figure out this headache. Was it a burst aneurysm (negative CT means we need an LP, he has some risk factors, but he's had this headache in the past and it didn't sound like a subarachnoid)? Is it an expanding subdural? Is it cluster? Is it a migraine? Or is it simply the cancer becoming intractable? Finally, after exploring the history, I got a sense it could be musculoskeletal. We tried cyclobenazeprine, a long-acting skeletal muscle relaxant. He was finally able to fall asleep. For that, I am thankful.

Medication Adherence

"Medication Adherence" from an August 2007 Pharmacist's Letter/Prescriber's Letter says that, "nonadherence costs over $100 billion yearly" and "36% of kidney transplant losses are due to nonadherence." These statistics really shocked me.

Poem: Fianchetto

Fianchetto

Only once did I get the holy man to work,
the day I sent Isolani to her death.
The rank and file in the market square
were getting restless, hemming in the bad bishop,
fending off black crusaders who would,
if their flat-footed dictator permitted,
dismount and enjoy the country air.
Deadlocked, it seemed, until my girl
walked past those pitchforks,
offered herself en passant to heaven
distracting those stalwart demonstrators
outside the corner castles,
one of which would be toppled
by this brilliant fianchetto
prayer beads gleaming, invoking Caissa,
justifying a gambit made by a peasant woman.

The Difficult Patient

I recently took care of a "difficult patient." He was a medical records researcher who had a lot of physicians in his family. He presented with a recurrent deep vein thrombosis and he knew a whole lot about DVTs and anticoagulation. He would argue with us; "last time I was here, I got a higher dose of heparin." When we came to see him, he liked to regale us on pharmacokinetics, interrogate us on the orders we were putting in for him, and challenge our decisions. It wasn't bad; it's kind of nice having an over-educated patient, but at the end, he began overstepping the boundaries. One morning, when the phlebotomist came by to draw blood, he ordered himself a "CBC" and "Chem-10" (standard labs for blood counts and chemistries). Our resident was paged to see if she wanted to co-sign the patient's order. Then later that day, he somehow directly paged our attending to ask about medications. This was totally inappropriate; I've never even paged my attending. I have to admit, he's pretty resourceful and he's working the system. But I hope if I get hospitalized, I never end up like that.

Medical Mystery

I admitted my first patient on cardiology nearly four weeks ago, a transfer from an outside hospital. It took us over three weeks to make a diagnosis, a fascinating story which unfolded as each path we went down lead to a dead end. Hindsight is 20/20, but I think I should have gotten the diagnosis earlier. This post is technical and I'm not sure I have everything correct, but here are my thoughts.

A 63 year old woman with a history significant for a psoas abscess two years ago and a questionable exposure to TB presented to an outside hospital with two years of increasing anasarca - swelling of her entire body. This started since her hospitalization for the psoas abscess and since then, she's gradually retained fluid until her legs are so swollen she has severe pain and cannot walk anymore. The exam showed pitting asymmetric 4+ edema in both legs, a holosystolic blowing murmur best heard at the left lower sternal border, and a blood pressure of 100/40.

At the outside hospital, she was worked up for renal, hepatic, gastrointestinal, thyroid, and autoimmune causes for swelling, which were all negative. An echocardiogram showed preserved systolic function but right heart enlargement and severe tricuspid regurgitation. She was then transferred to our hospital for work-up for pulmonary hypertension.

Our repeat echo confirmed elevated pulmonary pressures and we decided to focus on that differential. I read up on the WHO classification and began to explore each possibility. The echo showed no left heart failure. CT and pulmonary function tests suggested it was not a primary lung problem. To rule out chronic thromboembolism, we did lower extremity dopplers (negative except for a small AV fistula) and a V/Q scan (negative). There were no systemic symptoms suggesting collagen vascular disease, sarcoidosis, or rheumatologic illness. She denied drugs, was HIV negative, and had no other medical conditions. At this point, I started feeling like this could be idiopathic pulmonary hypertension.

But one attending suggested looking at the heart. He felt this could be constrictive pericarditis, especially given a questionable history of TB. A cardiac MR was negative for pericardial disease so we decided to do an invasive right and left heart catheterization. This showed increased pulmonary pressures, physiology of a restrictive cardiomyopathy, and high output heart failure.

For the restrictive cardiomyopathy, we took several heart biopsies. I was convinced this was a disease like sarcoid or hemochromatosis or amyloid, and that this woman would need a heart transplant. But then the biopsy came back completely negative: no Congo Red staining, no iron deposition, just nonspecific fibrosis, "cardiomyopathy NOS" (not otherwise specified).

We were stuck, still no good answer. But word of this patient spread through the department and some of the most expert clinicians at UCSF came by to see her. Eventually, they felt that this was not a cardiomyopathy but simply "severe tricuspid regurgitation causing a reverse Bernheim effect." Bernheim was a pathologist who described in 1910 a theory that left ventricular hypertrophy could impinge on right ventricular filling. This turned out not to be the case. But the reverse Bernheim effect describes a scenario where right ventricular enlargement impinges on left ventricular filling. Indeed, this patient had a dilated RV and left diastolic dysfunction.

The proposed treatment was tricuspid valve annuloplasty, a highly risky operation. We consulted the cardiothoracic surgeons and they consented the patient for the procedure. Around this time, a student nurse who had just come onto the service told us he heard an abdominal bruit. We brushed it off at first, attributing it to hearing the tricuspid regurgitation in the abdomen of this very small woman. But this student nurse actually made the most critical finding.

An angiogram revealed this was a massive arterio-venous fistula probably originating from the incision and drainage of the psoas abscess a few years ago. It was so large that it shunted a lot of blood past capillary beds. As a result, there was low systemic resistance and a high output heart failure. The increased venous return led to right ventricular dilatation and tricuspid regurgitation. As blood was shunted away from the kidneys through the A-V fistula, the body began retaining fluid and she became overloaded and edematous.

Over the last three weeks, the proposed therapy was lung transplant (idiopathic pulmonary hypertension), then heart transplant (cardiomyopathy), then tricuspid valve annuloplasty, and now finally vascular surgery which may resolve all the abnormal physiology. The clues were in the history and physical: the edema began after this psoas abscess (initially dismissed as irrelevant), she had an unusually large pulse pressure, and the student nurse heard a bruit over her femoral artery. It was a fascinating case, but one that could have been solved earlier if we kept re-evaluating what was going on as new information came.

Tired

I'm tired. I've been in the hospital 24 of the last 25 days; I had two black weekends (days when we have to go in both Saturday and Sunday cause of the call schedule). I'm looking forward to Thanksgiving.

"Don't be humble. You're not that great." - Golda Meir

The Differential Diagnosis

One of the main things I'm learning is how to make a differential diagnosis. This is entirely different than making a diagnosis on a multiple choice exam. We've had several clinical scenarios that have clear-cut diagnoses. Yet as I listen to residents think these cases through, I realize that despite knowing the answer, they can still generate a rich library of alternate possibilities. This is an amazing ability to me. I'm too used to jumping directly to the one answer, convinced it cannot be anything else.

For example, we had a young woman present with altered mental status, fever, hypotension, and acute renal failure several days after she was diagnosed with a kidney stone at another hospital. She also had a low white blood cell and platelet count. This felt strongly of sepsis to me, perhaps compounded by DIC, and sepsis was the right diagnosis. But at resident report, I heard a wealth of fascinating diagnoses: she met all the criteria for TTP/HUS and someone threw out neuroleptic malignant syndrome since she got phenergan.

Another case: I admitted a young woman with cystic fibrosis presenting with a few months of productive cough and hemoptysis (coughing up blood). This felt like a clear-cut case of CF exacerbation. But my resident brought up the idea that given this woman's travel history, she might have TB. Once he said it, it made sense. The answer was CF. But to forget TB (especially in San Francisco) would be a mistake.

It is important to think in broad strokes for several reasons. Cases can be sold in almost any way. I can take a case of a pulmonary embolism and make it sound like acute coronary syndrome or a pneumothorax or a pneumonia. I've seen this done. The ER can pawn off a non-cardiac case to cardiology simply by making the story sound right; no lying is involved, it's just putting the right emphasis on things. And how cases are presented colors our perception subconsciously. So given any case, I need to remember to keep an open mind and a broad differential (at least in medicine; the opposite occurs in surgery).

The Stanford Fund

Those who participated in extracurriculars at Stanford know The Stanford Fund well. In order for student groups to get funding, members have to write Stanford Fund letters (not to be confused with fun letters). We hand-wrote letters of appreciation to donors emphasizing how The Stanford Fund has personally affected our education. I actually love hand-written letters and I think it is a lost art. But writing dozens of fund letters is really time-consuming (I'd spend half of rehearsal finishing mine up).

I donate a token sum every year, and this year, I was shocked to get a taste of the Stanford Fund letter. To encourage more donors, an inspiring undergrad sent me a (typed) letter of her life story. Having written fund letters, I think it's funny how I can identify the key elements of the format they stipulate. In any case, I was pretty amused to receive one of these things I spent so much of undergrad writing. I don't want a hand-written one though, now that I know how tedious they can be.

Image from givingtostanford.stanford.edu.

SF

This is a picture I took at Fisherman's wharf earlier this year - it's a sourdough crocodile!

Deaths

I've only been on the general medicine service for one week, but we've already had three people pass away. I've ruminated a lot on this subject, on helping patients achieve their desired end of life, on the "good" death in comparison to the technologically laden modern death, on the limitations of medicine. But simply, what is it like to know someone intimately days before they die? How easy it is to become business-like, methodical, filling out the paperwork, asking for an autopsy. But standing in the room of the recently deceased, my thoughts wander and race. What has this man seen? Where has he been? What memories he must have deep within his brain, a trove that may never be unlocked. I picture a vast network of connections, some cliche spiderweb, each node representing a person. How many connections just withered away with this man's passing? What races through their minds, these people who actually knew this patient, had meals with him, shared triumphs and tribulations with him? I only had a glimpse of this man's nature, perhaps only the skeleton that remained at the end of life, and how I must misjudge or mistake who he is. Now, his face looks ashen, and that is not the memory I think he would like me to have.

Revision: Emergency

Writing is easy. The discipline is in the revision. I recently workshopped an old poem at a newly revived Writer's group, so here's a second draft.
-
Emergency

Here the sound comes first
siren or scream, moaning or sobbing,
calling us from our stupor,
winding our way to the trauma bay

where the smell hits like a fist,
gunpowder and soot
stale urine, halitosis
even the sting of disinfectant

wiping the records board,
the highest blood alcohol
won by a teenager status post mosh pit
in the gurney next to another winner

a man who came in only after the batteries died.
I lay hands on the longest object
extracted from a rectum and want to yell
(I got seven inches, anyone beat a seven?)

The taste lingers all the way to the bathroom
where I spit up disgust and pleasure,
that adrenaline that drives me,
like these people, to come back again.

Health Care Disparities

I'm certainly not an expert on health care disparities, but I've begun to form my opinions after half a year on the wards. Of course, being at an academic institution in San Francisco colors my experiences, but health care disparities still exist. I've never seen conscious or deliberate manifestations of bias, stereotyping, or prejudice. But the problems I see are harder to solve. For example, I recently took care of a Spanish-speaking woman. Being good health care providers, we used translators liberally, especially in the initial history and physical as well as delivering important news and consenting for procedures. But despite this, I felt that there was a barrier in communication that I could not pinpoint. Although a translator ameliorates literal problems, it does not eliminate the communication barrier. Something's different about this social situation with another person in between me and the patient which may lead to less patient satisfaction, patient understanding, and overall rapport.

Autopsy

On medicine, we recently withdrew care from one of our patients (a different one than the patient mentioned several posts ago). She spent a prolonged period in the ICU and we could not achieve her desired quality of life. Finally, through discussions with the daughter, we withdrew care in concordance with the patient's advance directive and pre-stated wishes.

The daughter allowed us to do an autopsy. Autopsies are fundamentally important to the advancement of medicine. Although they obviously cannot help us care for the patient, they influence our care for future patients. Doctors no longer do their own autopsies, and the rates of doing them have gone down. But I think the educational value of an autopsy is often underestimated. It's the gold standard for pathology. It is how we learn our mistakes, our limits, and our successes. It helps physicians achieve closure in a difficult and trying case.

We went down to see the autopsy results. The pathologist went through all the different organs, pointing out things we wouldn't have known otherwise. It reminded me a lot of the first two years of medical school, the stinging formaldehyde, the palpation of organs, the didactic nature of medicine. And I think that the autopsy really generated a deep regard and respect for the human body and its wonders.

Internet Rounds

I just wanted to post some links to interesting websites:

http://www.google.org/flutrends/ - A cool new Google gadget.

The New England Journal of Medicine recently ran a series of articles discussing primary care and the crisis in health care.
http://content.nejm.org/cgi/content/full/359/20/2085
http://content.nejm.org/cgi/content/full/359/20/2086
http://content.nejm.org/cgi/content/full/359/20/2086-a
http://content.nejm.org/cgi/content/full/359/20/2087
http://content.nejm.org/cgi/content/full/359/20/2087-a
http://content.nejm.org/cgi/content/full/359/20/2087-b

The Anatomy of Dying

(Some details changed to protect identity.)

At age 68, Mr. A walked into the emergency room. He was a little short of breath but 2L of oxygen by nasal cannula relieved his difficulty breathing. In childhood, he had rheumatic heart disease, and as a result, his aortic and mitral valves had failed. About twenty years ago, he had the valves replaced with mechanical valves, and those had served him for far longer than the artificial valves were expected to last. He was admitted to the hospital for presumed heart failure; perhaps the valves were finally giving out and his heart was having difficulty pumping blood. His other medical conditions included systemic lupus erythematosus (SLE).

The assumption was that as the heart failed to pump blood forward, it was backing up into his lungs, causing pulmonary edema. Our treatment was aggressive diuresis, to cause him to urinate out all the extra fluid. However, day after day, he was not improving; his oxygen requirement slowly went up and he was unable to sleep lying flat, a symptom called orthopnea which often characterizes congestive heart failure. One day, his symptoms and oxygen requirement drastically shot up to 10L by nasal cannula.

Chest X-ray and a CT scan didn't show any good causes for the increasing dyspnea (shortness of breath). On a ventilation-perfusion scan, a defect was identified that showed "high probability of pulmonary embolism." A pulmonary embolism or PE is a clot thrown to the lungs that obstructs blood flow and can cause low oxygen levels. Interestingly though, Mr. A was on an anticoagulant at supratherapeutic levels (INR 3.5-4.0) for his mechanical heart valves. Someone at that level of anticoagulation should not be clotting; in fact, he would be at high risk for bleeds. However, Mr. A had one condition that did not make this impossible; lupus (SLE) is sometimes associated with a prothrombotic state ("lupus anticoagulant," a misnomer) that can break through therapeutic anticoagulation (the other possibility was an occult cancer).

This conundrum confounded us for days. How could he clot on anticoagulation? And given a probable PE despite anticoagulation, how should we manage him? We consulted numerous services: hematology, pulmonary, rheumatology, intensive care, anesthesiology, and the congestive heart failure service.

Meanwhile, he was getting worse and worse. He required high-flow oxygen (15L) or a non-rebreather mask. He could only tolerate sitting straight up at 90 degrees. He spoke in two to three word sentences. He was getting no sleep. He was stressed, tired, and despairing. Originally, he and his wife thought they could be out of the hospital by Thanksgiving. But things were getting worse and worse.

We began heparin in conjunction with warfarin, two powerful anticoagulants with a considerable bleeding risk. But weighing the risks and benefits, we knew that another PE would kill this patient. We sent off fancy lab tests: chromogenic factor X and markers of prothrombotic states in an attempt to fully characterize what was happening.

We began talking about "goals of care," perhaps a euphemism for admitting that medical care was not making this patient better. This was a tough discussion, perhaps the hardest among those I've experienced. Between the lines, we were saying that he was dying and we wanted to know how far to go. He didn't want prolonged intubation (being on a breathing machine) or heroic measures of resuscitation. But he wanted to get better; his son from Texas was visiting for Thanksgiving, and his wife was by his bedside every day, unfailingly.

Given the situation, we decided to act. A trans-thoracic echocardiogram was not giving us valuable information. The patient could not tolerate going to a scanner or a trans-esophageal echocardiogram (a better test at looking at the heart). We kept diuresing and diuresing but we could not wean his oxygen. We needed to look at the lungs. We intubated Mr. A and brought him into the intensive care unit.

A bronchoscopy showed his lungs were full of blood - not water. Instead of severe pulmonary edema from congestive heart failure, he was bleeding profusely into his airways. Our aggressive anticoagulation probably made things worse. But, we said, he had a PE. How was he clotting and bleeding at the same time? We were also losing vascular access. Nurses couldn't get an IV started because he bled with every stick.

We stopped the anticoagulation and began aggressive ICU support. Sedation kept Mr. A comfortable, but we could not wean him off of the ventilator. His renal function began declining (Cr baseline 0.7, now up to 1.6). His blood pressure began to drop, and one day, his liver function enzymes skyrocketed (AST/ALT in the thousands). This was probably shock liver, maybe from ischemia, maybe from a clot. And now several organ systems were shot - cardiovascular, pulmonary, renal, hepatic.

Multi-system organ dysfunction has a very poor prognosis. After numerous discussions with the wife, we decided to withdraw care. After stopping the pressors (cardiac medications to maintain blood pressure), Mr. A passed away in less than half an hour. I learned a whole lot from this case. From a medical standpoint, I realized how difficult it is to operate beyond the realm of data; much of what we were doing had never been studied. I learned how important it is to re-evaluate constantly; we treated a long time for pulmonary edema, and perhaps there was some component of it, but it did not explain the entire picture. From a patient care standpoint, I realized the import of the end of life, how to approach it, how to accept it.

On Illness

"On Illness" by Virginia Woolf

How common illness is, how tremendous the spiritual change that it brings, how astonishing when the lights of health go down the undiscovered countries that are then disclosed, what wastes and deserts of the soul a slight attack of influenza brings to view, what precipices and lawns sprinkled with bright flowers a little rise of temperature reveals, what ancient and obdurate oaks are uprooted in us by the act of sickness, how we go down into the pit of death and feel the waters of annihilation close above our heads and wake thinking to find ourselves in the presence of angels.

Poem: Not a Person, but an Institution

Not a Person, but an Institution

My grandfather is dying six thousand miles away
while I am fishing from a fishtank
with a character named Fiji
among scattered charts and half-eaten donuts
drinking coffee like water this midnight at the office
trying to get the last numbers to pan out,
this far removed, a sanctuary built
of technology and occupation
so different than the world of my grandfather
who practiced pediatrics from the first floor
of his house, the line of babbling babies
stretching out the door,
a time which has gone out and around the block.

Cardiology

In a whirlwind, two weeks of cardiology went by, so little time to learn an incredible amount of material. I focused primarily on practicing the cardiac exam. I got to see and hear a wide range of normal and abnormal findings, from hepato-jugular reflux to murmurs and gallops to parasternal lifts. The range of patients was diverse, from the standard heart attack (STEMI vs. NSTEMI vs. unstable angina) to common complaints like fainting or cocaine chest pain ("crackycardia") to complicated mysteries (we were transferred a patient from another hospital and the work-up showed constrictive pericarditis vs. restrictive cardiomyopathy vs. reverse Bernheim effect from tricuspid regurgitation). I got to admit and work-up a few patients, follow them through their hospital stay, and decide what tests and treatments to order. I got a little more comfortable at reading EKGs and learned about fancy things like intra-aortic balloon pumps and trans-esophageal echocardiograms. Teaching rounds covered congenital heart disease, stress testing, arrhythmias, and more.

I had a fanastic time on the rotation. The teams were small but the teaching was abundant. The service has a high turnover of patients so I was exposed to a generous amount of cases. We had CCU (cardiology ICU) patients, consults, and regular floor patients. I loved thinking through the physiology of the heart. A cardiology guru Dr. Chatterjee does amazing bedside teaching; his physical exam is unsurpassed and he is known for predicting the results of invasive tests with unbelievable accuracy (he predicted my patient's CVP, EF, and stroke volume just by exam). As a whole, I loved the analytical thinking, the strong evidence-driven medicine, the variety of diseases, tests, and interventions, and the culture of cardiology.

America's Best Surgeon

America's Next Top Model, The Apprentice, Project Runway, So You Think You Can Dance, American Idol...all tried and true. What could go wrong with America's Best Surgeon? Imagine how your patient base would balloon if you won the show. And the competitions? How about having two surgeons, one blindfolded and operating, and the other giving verbal instructions? Or maybe you can only use your non-dominant hand. Or having to operate underwater or upside down (car mechanics do it). We've got a bunch of medical dramas, how about a reality show? (Imagine a patient coming into your office, "Hi Doctor, have I seen you before? Oh wait, weren't you eliminated in round 1?")

Image is a promotional photo of the cast of Doogie Howser, MD, taken from Wikipedia, shown under fair use.

Internal Medicine

Ah yes, I have arrived at the most fundamental of rotations, internal medicine. I've really been looking forward to this clerkship, focusing on the care of the hospitalized adult patient. It is at Parnassus (Moffitt-Long hospital, home of the Moffitteers), a tertiary care center with complex, sick, and intense patients. Internal medicine is a foray into a vast collection of diseases, both common and eclectic, with a particular focus in the differential diagnosis and management of diseases of the heart, lungs, kidneys, endocrine system, gastrointestinal system, and the blood, including cancers and infections. It draws upon all the knowledge we gained (supposedly) in the first two years of medical school and has the reputation of being a solid, time-consuming, learning-heavy rotation.

Here, we do two weeks of cardiology (which I have started with) and six weeks of general internal medicine. Call is every fourth night and students admit 1-2 patients each call night and do not stay overnight. The teaching is abundant with noon conferences, attending rounds, resident report, and medical student lectures. I've found that so far the hours are quite manageable coming off of surgery; I walk to the hospital (a welcome change) at 6:30 and I get out at a reasonable hour. We work 6 days a week, and I have become accustomed to just needing 4 days off a month. My current cardiology team consists of a senior resident and an intern (who I knew previously from lab) and it's fantastic; the team dynamic is smooth, respectful, and efficient, and the resident takes time out of her schedule to teach. This is really what I wanted and expected in a third year clinical rotation.

600

This is the 600th blog since my first post September 1, 2006. I planned this one to be about the mid-point of my third year and serendipitously, it fell on election day. I honestly do not believe this, but my calendar tells me I have completed 3 out of my 6 blocks of required third year rotations. Inconceivable! I've spent half a year taking care of patients full time, immersing myself in the culture of medicine, learning, doing, and teaching. Yet I feel as underprepared as my first day (though I hope in actuality, I have gained something in the last six months). Though I feel like I know more, much of the growth is also in learning the practical aspects of medicine, how to work in a team, how to interact with patients, how to think and plan.

Third year rotations have this odd sensation that, during any particular day of a rotation, it feels like forever, but after the rotation, I can't believe how quickly it went by. It's a little scary to think that perhaps I've finished my last psychiatric mental status exam or evaluated my last acute stroke patient or scrubbed into my last surgery. Everything feels too premature and I'm a little sad about it. Only now do I realize how much more there is to learn, how much depth there exists in each field, and how fascinating these disciplines are.

A year from now (faster at this rate), I will be interviewing for residencies, paying my last year of tuition, with a firm idea of what specialty I would like to pursue, and as a result, what I would like to spend the rest of my life doing. That's simply mindboggling. Up to now, I've been putting off "real life," pursuing more and more school, majoring in philosophy, heartily avoiding real jobs. I want to do everything and yet I don't want to settle as a jack of all trades.

Have these six months solidified my confidence in medicine as a career? Yes and no. There are things I love about medicine and would never give up (the puzzle and pursuit of the answer, the science and physiology, the obscure and esoteric) but there are also things I frankly dread (dealing with paperwork, systems problems, devastating or fatal injuries). Now I've seen first-hand how hard and long the road is, and it's making a huge impact on me. Seeing what interns go through frightens me, and I wonder if this is the path I want to pursue. Is this a problem? I think that (except among surgeons), doubt is natural and not a problem. At least it helps me narrow down my specialty interests. What those are, I'll have to defer to another post.

Poem: Death by Death's Paces

Death by Death’s Paces

Bad habit, the ears of a rabbit
Bad habit, counting boxes this Sabbath
Bad habit, Sinclair Lewis’ Babbitt

Bad habit, running under trees this thunderstorm
Bad habit, hanging lanterns on a barge
Bad habit, playing Operation with utensils
and an outlet / for bad habits, the celestial discharge

Bad habitat, a residue of this world’s wealth
Bad habit, worn by Judas himself

Bad habit, death by death’s paces
Bad habit, this book of faces
Bad habit, trainspotting St. Peter
Bad habit, drinking another liter

Bad habit, I know and I say
That bad habit dies today

Fall Back

I edited the last post with a different quote, more in line with All Saints' Day, and instead copied that one into today's post.

Interestingly, the daylight savings' hour change was the big topic of discussion among the residents on call. While everyone else cherishes that extra hour, the residents on call were bemoaning the fact that their call was extended another hour.

Overheard on a rainy and dreary Saturday afternoon, on call in the hospital:
"The new resident work hours [capped at 80 hours a week] have changed a lot of things. Before that, some surgery programs were known for having sky-high divorce rates. In fact, some even had greater than 100%, from people who would get divorced twice during residency."

Happy All Saints' Day

Overheard: "God heals, the doctor collects."

Happy Halloween

Zoro, Surgeon.

Muldoon

Last Friday, I had the rare and amazing opportunity to work with one of the preeminent poets of our time, Paul Muldoon. A 2003 Pulitzer Prize winner and poetry editor of The New Yorker, Muldoon is an Irish poet who teaches at Princeton University and is known for "difficulty, allusion, casual use of extremely obscure or archaic words, understated wit, punning, and deft technique in meter and slant rhyme" (Wikipedia). He was invited to UCSF/Berkeley and gave a medical humanities grand rounds here.

In the afternoon, he also held a special poetry workshop in which a few writers of the UCSF community gathered to get input on their poetry from Muldoon. Soft-spoken and articulate, his insight was remarkable. He then gave an hour long talk, reading a substantial amount of poetry, some related to medicine, death, birth, and meaning. His delivery was awe-inspiring, and simply his facility and knowledge of words was unsurpassed (it's a strange talent to have, but one that makes a good orator). I thoroughly enjoyed the richness of his language and poetry. It was a rare and welcome treat.

Image shown under fair use, from princeton.edu.

Resource Allocation

We got a talk by Mitch Katz, Director of San Francisco's public health department, a really daunting job. He has a fascinating approach to and perspective on health care. He really sees things from a birds-eye view, and it's an intimidating task. To him, tax-payer money needs to be funneled into optimized health care outcomes, something few people would argue with. But he faces the reality of modern day medicine, meeting an annual budget, which focuses entirely on the ethical issue of distributive justice: how do we allocate resources fairly?

For most doctors, we want the best for our patients. Expensive drugs, fancy scans, resource intensive tests, an extra day in the hospital - it's all for the patient's good. But for those patients who are uninsured or underinsured, the hospital has to absorb the costs, and San Francisco General Hospital is run by the public health department. Dr. Katz finds himself the enemy as he tries to contain costs by changing the pharmacy's formulary or mandating that only attending physicians can order certain drugs or denying the purchase of a new scanner. How can there be so many barriers to patient care? We ask. But the truth is, the bottom line matters.

Indeed, we think it's always hypothetical that a patient staying an extra day in the ICU incurring thousands of dollars in cost translates to fewer vaccines for primary prevention. Dr. Katz made a huge point in emphasizing that this is not hypothetical, that it is reality. Every test we order, every drug we prescribe, everything we do that isn't reimbursed fully takes something away from another patient. He thinks that money should be going into providing housing for the homeless because that will make the biggest impact on health care. No other doctor without a public health approach sees things this way. I find it so fundamentally important.

Hurricane Katrina

Perhaps a post too late to count, but I wanted to write a bit about Hurricane Katrina. During the disaster in 2005, Memorial Hospital was flooded and lost its electricity and emergency generators at a time when the temperature and humidity were nearly unbearable. When no governmental evacuation was apparent, staff and patients began evacuation but could not get everyone out. Some of the sickest patients who were unlikely to survive were left behind.

The ethical controversy occurred when a doctor was charged with second degree murder (though in 2007, a Louisiana grand jury refused to indict her). At the time of the hurricane, she went to the hospital to take care of the patients, many of whom were already abandoned by their health care teams. Some of those patients were suffering because the ventilators had failed and the pharmacy was depleted of necessary drugs; she administered pain-killers to some of those patients. She was accused of mercy killings of critically ill patients with lethal doses of narcotics with the intent of ending their life.

It's an important question to ask: what role, if any, should a physician play at the end of someone's life? If someone is terminally ill, has intractable suffering, is of sound mind and judgment, and requests an overdose of pain medication, what does one do? There are some who say physicians should have no involvement in ending a patient's life; it gives too much power to doctors who are fallible and who do not know everything. Others think that refusing to help a patient die who is in intractable pain is unethical of the doctor; as the ones who deal with dying on a regular basis, how can we abandon patients at this critical time? This is clearly a controversial issue and one I'm fascinated by but cannot resolve.

What if a patient says she is having trouble sleeping and asks for a prescription of barbiturates to help her sleep when you know her intention would be to commit suicide? Or what about the case of a person who needs escalating amounts of pain-killers to control his suffering until the point that he slips into a coma and passes away? How do we navigate responsibility and morality, life and death, when much of medicine is uncertain? In Oregon, physician aided death is allowed within strictly regulated boundaries. Is that immoral? Or should all the states follow suit?

Poem: Mythology, and Other Lies

Mythology, and Other Lies

How naïve was I to think that Palinurus
could resist Somnus’ call
as he pulled his third all-nighter
at the helm of a wayward ship?
Now, only the genus of the spiny lobster
pays honor to this constellation-seeker,
a pastime relegated to a past time
perhaps thirty thousand years ago
when Prometheus discovered
what we have only known this past century:
the liver, with the succor of ambrosia and nectar
defies absolution
and we might wonder
if Prometheus had not faced such procrustean punishment
what he would have done next,
whether he would have continued such philanthropy
and earned himself a following of clerisy.
Perhaps without his insight, we would never have devised
the procedure we now know as the transplant,
a term that conjures the idea of sexually ineffable bryophytes
and ferns and fern-allies.

I was once told that poesy deigns all else
but sex and the dead,
the kind of prompts that make us think of James Joyce
or Elvis or Tupac,
modern day lessons on resurrection.
Much like mules, we have history,
a history that winds and waddles canyon to crevice
finding itself perched on Parnassus, sacred to Apollo
and home to the homeless
clustered and scattered among the streets
of earthquake and fire, furious and fertile
hailing the tempest-tossed, the wind-swept.

Intersession

We just finished intersession, a week of socializing sprinkled with classes and adviser meetings. While at first I thought it was silly to have these week long transitions, I find them incredibly welcome reorientation and destressing sessions. The theme this week was ethics, and we had several lectures and small groups on how to approach ethical issues, think through them systematically, and argue for or against a course of action. The truth is, I never really liked applied ethics and a physician doesn't approach ethical theory as a philosopher would. But, what we did learn was practical and certainly the discussion of ethical problems overcomes a large activation energy in recognizing its importance. As an ethical purist though, I still find Kant's (praise be his name) theories most compelling.

Another big aspect of this week was professional development. Not only did we have our old foundation of patient care groups (which I thoroughly enjoy), we also had some scary sessions on how to plan our fourth year, the timeline for residency application, and when to take Step 2. I was able to meet with a couple faculty members for advising. Lastly, they try to emphasize professionalism in these intersessions, topics that are better taught by modeling rather than pedantics.

There was also a hodgepodge of other random topics such as master clinician rounds (demonstrating differential diagnosis and clinical reasoning of a difficult case), stem cells, and disabilities. As a whole, I thought the week went fairly well; I enjoyed seeing all my classmates again and I had a lot of fun hanging out with friends.

Specialties

After each rotation, I consider whether that could be a career. I've never thought myself a surgeon but I tried to go into the rotation with an open mind. Nevertheless, I did not find my passion here. For whatever reason, I do not particularly find the abdomen fascinating, and too much of a general surgeon's time is spent there. The rest, soft tissues, vasculature, the breast, and the neck, just don't do it for me. Anatomy was neither a strong point nor a strong interest for me, and I did not find myself drawn to the hospital care of surgical patients, even those with burns, trauma, or intensive care issues. Most importantly, I just don't feel a fit with the surgeon crowd (though of course, much diversity exists and stereotypes don't permeate the group) and I can't see myself with a surgeon lifestyle.

Of the subspecialties, I only really liked hand surgery, and I don't like it enough to give up the rest of the body. Though I like the intensity and immediacy of trauma, I do not have the personality for it and I cannot see myself dealing with that kind of injury process (especially when so much of it involves domestic violence). While I did not get much exposure, I cannot see myself doing colorectal, neuro, orthopedics, plastics, vascular, or pediatric surgery. I'm not sure about thoracic (having to go through general surgery deters me), urology, or ENT.

I also experienced emergency medicine. For a long time, I was very interested in the field, which is growing in popularity. However, I decided it was not for me. I loved the emphasis on efficient history and physical diagnosis, the procedures, and the focus on acute and life-threatening injuries. I also like the hospital-based aspect of it and the shift work hours. But after experiencing some time in that environment, I didn't feel a fit. There is a lack of appreciation, too much triage without follow-up, and the unfortunate reality that most patients in an ER do not belong there or should have had their medical needs addressed earlier by a primary care doctor.

Surgery 110

In sum, the surgery experience involved a lot of practical learning and growth. The positive aspects of the rotation encompassed the operating room and procedures. Compared to stories I've heard from others, I got to do as much or more hands-on things in Fresno than students at other locations. I feel pretty good about my suturing and I really enjoy it; even though stitching can be tedious and repetitive, I like using my hands. I got to place two chest tubes, an arterial line, attempt some femoral artery sticks, and put in a Foley catheter, which is quite good for a third-year medical student. I was given a lot of responsibility and felt that I really was the caretaker and advocate for my patients. I got to rotate through multiple services, see common surgeries (I've had my fill of hernias and gallbladders) as well as complex cases (thoracotomies, cancer surgeries), assess clinic and ER patients for surgical intervention, attend trauma activations, care for patients with traumatic injuries, see plastic surgery, and learn about burn management. I really appreciated the diversity of experiences they offered.

However, I found that the formal didactics were mediocre. I did not think I learned a large body of knowledge, though certainly I nibbled at the entity that is general surgery. I found some personalities to be abrasive and arrogant, and I experienced some less-than-optimal situations. Tensions and stress were high with the patient load we had, and I often felt that teaching was secondary to more urgent needs. I didn't find myself connecting with any particular surgery attendings or residents. Students were too busy to study outside the clerkship; though call was a unique experience, it was incredibly draining. Through much of the rotation, I did not feel appreciated, and at times, I felt like I was doing more scut (busy work) than necessary. I recognize that Fresno had a lot of constraints and acknowledge that investing in students is a tiring and difficult business, but I wish student learning was more valued.

The Purview of Surgical Practice

Surgery has become a commonplace concept, a household term, even a cosmetic high school graduation gift, but after spending two months delving into surgical practice, I still find it a fundamentally stirring concept. A surgeon takes a blade and cuts into another person's body with the assurance that doing so will leave that person better off than before he or she came in. That takes a lot of confidence (and people with confidence self-select into the field).

It amazes me. I never think of this in the moment, when I am handed a scalpel and told to make a careful premeditated incision (a euphemism for cutting on a dotted line). But afterward, I realize I had to have enough confidence in my medical judgment, knowledge, and skill to justify intentionally cutting someone. Of course as a student, my supervisors really make the decisions, but it is my responsibility to object or refuse to do a procedure if I am not convinced that the patient needs it or that I can do it safely.

This can be extended to all of medicine. Over the last six months, I've seen many patients: diabetics started on oral hypoglycemics, hypertensives that needed medication management, cuts that needed stitches, patients who needed drugs for pain. In all cases, doctors actively do something to the patient with a degree of confidence that they are doing what's best for that person's well being. Even simpler things have this quality: deciding to X-ray someone or doing a pelvic exam or taking a history. When I feel for lumps in a middle aged woman's breast or ask a man to undress to assess for hernias or ask a teenager when she last had sex, those patients trust that I am invading their privacy because I can help their health, and I, too, have to have that certainty that I can justify what I'm doing.

Surgery is the extreme. We take a naked person, we put them to sleep, we cut them open with a knife, poke around their belly, and then sew them up again, sometimes for an optional, elective procedure. Doctors have the unique position of being able to do this with the schooling that prepares us, the legal right that backs us, the experience that hopefully tells us when invading someone's body or someone's privacy can be justified. There is something quite thrilling as well as something quite scary about having that privilege.

Image is in the public domain, from Wikipedia.

Poem: Other Poems

Other Poems

In other poems, death is a persona
riding a chariot, carrying a scythe
sometimes with a bit of halitosis
or sporting a cigarette and smoke rings.
I’ve read of death teaching morals
helping old ladies cross the street
on their way to the funeral home.
In other poems, death can be funny
or grave and punny
or grandiose or peaceful
anthropomorphized and personified.
Death sometimes acts the role of a metaphor
for something lost or something gained
a bit of trickery or a hint of judgment
an insurmountable foe
at the end of the tunnel.
In other poems, death is an allusion
or an illusion, a doppelganger
that takes on any number of costumes
than that it wears at home.

Week 8

My final week on surgery was an abbreviated one. We only had clinical duties on Monday and Tuesday (along with rounding over the weekend). Other than taking care of the same burn patients, I was in a couple hand surgeries. On my last day of the rotation, they let me use a scalpel! (Actually, I had used one to put in a chest tube, now that I think of it). A young man had a pyogenic granuloma on the finger, a ping-pong sized erythematous friable (red, easily bleeding) mass forming at a site of prior trauma (he had hit his finger with a hammer). He was put under conscious sedation and I carefully cut it off. The second case was a carpal tunnel release, a quick but good procedure to see. In clinic, I saw a few standard plastic surgery cases: a thumb crushed in a car door, a breast reduction.

Tuesday evening, I drove back from Fresno to San Francisco. It's really good to be back; October is a beautiful month in the city. We had two days to study for our shelf exam on Friday. Our evaluations in this clerkship have a few objective components; we had to do an observed abdominal exam with a faculty member and present a couple annotated researched H&P's to our preceptor. But the looming menace was the shelf, which has a reputation of being quite tough. Along with a tight time constraint, the surgery exam tests aspects of orthopedics, neurosurgery, urology, and pediatric surgery, which we have to review outside of our rotation. A lot of it (surprisingly) is medical management: how to work up abnormal electrolytes or decreased urine output or post-operative fever. In any case, it was an intense exam but it went fine and marked the end of my third rotation and, more frighteningly, the half-way point of my third year.

Week 7 and a Short Break from Blogging

Aside from the burns and plastic surgery cases I did, I also had some interesting operations when I was on call. We had an intra-operative consult from ob/gyn. They were doing a hysterectomy and salpingo-oophorectomy in a woman who had many previous abdominal surgeries. As a result, she had a lot of adhesions involving her small bowel. Ob/gyn wanted us (trauma surgery) to come and take down the adhesions because of the danger of damaging the bowel. Afterwards, I got to see them do a partial hysterectomy and take out surprisingly large fibroids. It was interesting seeing the role of multiple surgeons working on one patient. We also had an acute appy which we took out laparoscopically and a patient who had a near amputation of a distal middle finger. Unfortunately, the finger was not salvageable and we had to complete the amputation and sew up the end. The other thing that happened this week was that the chief of surgery and his wife invited the students over for dinner. That was quite nice, and I learned a lot about the history of Fresno and the hospital.

I have decided to take a short one week break from blogging. The next blog will be next weekend. I'm going to use the time to study for our surgery shelf exam.

Plastic Surgery

For plastic surgery, we work mostly with a hand surgeon who I really like. Hand surgery is really different from the other surgeries I've seen. It's especially meticulous and precise, almost perfectionistic. Every motion is exactly as it's intended, every cut premeditated, every suture carefully tied. If it's not satisfactory, the surgeon redoes it. It seems that the margin of error for a tendon repair, compared to an intra-abdominal exploration, is a lot smaller. There are other differences, too. The surgeon sits, the tools are more delicate, the arm is put in a tourniquet to produce a bloodless field, and splints are used to maintain the position of various joints.

I've scrubbed into a lot of surgeries, including cyst excisions, scar revisions, tendon repair, exploration of stab wounds, palmar fasciotomies, ulnar nerve release, and scalp cyst removal. I really like the dissection of tendons, vessels, and nerves; for some reason, this is more exciting than laparoscopic dissection of the biliary tree or poking around the omentum. To be honest, if you had asked me that in my first year, I would have said the opposite; dissecting out nerves, vessels, and ligaments is horribly tedious. But now seeing the real thing, I'm really enjoying it.

Burns

This week, I switched over to the burns and plastic surgery service. They are very different entities. The burns service is a small one; as you might expect, severe burns requiring hospital stays are uncommon. The burns unit takes care of people with burns covering much of their body surface (from just 20% to 70%), deep third degree burns, burns involving the face, hands, genitals, and chemical or electrical burns. These patients are seriously ill. The patient I'm following was in a grassy hill when he fell asleep with a lit cigarette; another patient developed toxic epidermal necrolysis, a rare drug reaction with a 30-40% mortality; yet another patient is a psychotic patient who dumped herself in gasoline and lit herself on fire. It's actually really hard emotionally working in the burns unit; many patients don't even look human anymore. They cannot communicate, some have limbs amputated, and they are kept alive by invasive machines and monitoring. The surgical operation we do for these patients is skin grafting; we either harvest split-thickness skin grafts from the patients themselves or attach onto denuded tissue skin from someone else; sometimes, with large surface areas (imagine having to cover a whole back with skin), these patients look like a patchwork quilt. It's not hard surgery and students get to do a lot of suturing and stapling. But definitely not something I'd be interested in doing in the future.

Service

"Life is short and the art long, the occasion instant, experiment perilous, decision difficult." - Melvin Konner

Week 6

The second week on trauma really drained me. The days start at 6 but consistently end at 8pm, and even though 14 hours isn't absurd for surgery, ending that late ends up being really draining. I took care of a lot of ward patients (our census went up to the high 40s) but only scrubbed into two surgeries: an emergency laparoscopic appendectomy (I got to fire the stapler which cuts the appendix from the rest of the bowel) and a laparoscopic cholecystectomy. It was fun even though they are not particularly stunning procedures. The rest of the week was fairly unremarkable. The weather has been cooling down here and on Sunday, a few of us had a barbeque outside (students on other clerkships actually have free time).

Poem: Emergency

Emergency

After work, the board is wiped,
a new tally made to see who nets
the highest blood alcohol
or longest object extracted from a rectum
(I got seven inches, anyone beat a seven?)

The regulars stumble in
ordering a round, putting it on the tab
another shot of Ativan
before collapsing in bed in the hallway

Here, the sound always comes first
siren or scream, moaning or sobbing,
calling us from our stupor, winding our way
in anticipation to the trauma bay

where we hit the smell like a fist,
the burnt flesh, gunpowder and soot
the stale urine, the halitosis
the disinfectant with the sting of feces

Then the sight, the drunk men
victim of assault, now returning the favor
or the teenager status post mosh pit
or the pregnant woman rolled from a moving car

I lay hands, feel that Rice Krispie crepitus
along the neck of this upstanding
seventeen year old, shot by the owner
of a convenience store he tried to rob

The taste lingers all the way to the bathroom
where I spit up disgust and pleasure,
that adrenaline that drives me, like these people,
to come back again, again, again.

The 15 Minute Visit

How can we manage a new patient in a practical manner given a very limited interaction time? A full medical student history and physical can take up to an hour, but certainly we cannot afford that luxury in the real world. Dr. Kopes-Kerr, one of the program directors for Santa Rosa Family Medicine, tries to maximize the efficiency of a 15 minute first visit. Here's what he suggests:

-Start with the medication list.
-From the medication list, build a problem list.
-Get basic demographics, household information, occupation (especially for those of lower socioeconomic status).
-Defer family history, which is often complex, time-consuming, and low yield. Do this only if you have a clinical indication (cardiac risk profile, breast cancer, alcoholism, mental health disorder).
-Immunizations, which I personally never think of, but it's an important aspect of family medicine. Document last tetanus, flu, and pneumococcus vaccines. Copy immunization cards for children and give any that are clearly behind.
-Cancer screening: last Pap smear and if there has ever been an abnormal result. Defer all other cancer screening (mammogram, PSA, colonoscopy) for later visits.
-Lifestyle review: exercise, diet, tobacco, alcohol, drugs, stress. This gives information and also centralizes the importance of lifestyle in family practice. Do a coronary artery disease risk profile.
-If there's no chief complaint, then a physical exam isn't necessary. It may reassure the patient and build rapport, but beyond that, it's low yield in a first intake H&P.
-Instead, focus on the message the patient leaves with: what is the principal action or behavior they need to do now and why; how should they take their medications; when do you want to see them next and why.

Many people lament the lack of time in a standard clinic visit. I don't know what the answer is, but here's a possibility.