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.