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."