Wards

On Monday, I officially moved on from psych (well, technically I took the exam last Friday, but whatever) and began the three month adventure that is Internal Medicine. Medicine is our longest rotation of the year, and rightfully so, as no matter what type of doctor you end up being, the basics of how to care for sick adults is going to come up on a daily basis. Luckily, they break up the 12 weeks for us a good deal--we spend a month on the wards (the hospital floors where the sick people get admitted), a week on palliative care, three weeks on one subspecialty (something like cardiology, GI, endocrinology, infectious disease, nephrology, or ICU medicine), two weeks on another specialty, and two weeks on vacation. During my vacation weeks, I'll be spending a week in the NICU playing with tiny babies. The fact that I'll end my semester doing so is probably the happiest news I've received in months. I mean, have you seen how cute and tiny they are?!?! (Ahem. I digress.)

I was actually really excited to start medicine because, unlike psych and ob-gyn which are so focused in scope, here I would finally get around to something that felt like doctoring. Learning how to manage patients with everything from pneumonia to heart failure to cancer to HIV. Stretching my skills at diagnosis and discovering the best treatment modalities for things that I've heard about on paper but never seen in real life. The fact that I've still not ruled out med-peds as a dual specialization for residency was in the front of my mind when I started on the wards at our local VA medical center Monday morning.

Sadly, so far the experience has not exactly been what I was hoping. The first day or two were quite frustrating--full of lots of sitting around with nothing to do, working with residents who will leave me tomorrow and move to a new rotation and therefore have essentially stopped caring about anything but their most essential duties (not to say they're not caring for patients, mind you--they just don't really care about things like teaching me to use the computer system or going through a differential for my patient with a probable stroke). I get to start working with a new team tomorrow and Saturday, and I'm hoping they might be a little less jaded from their month at the VA and a little more enthusiastic about teaching. It's hard to figure out if you really might like to work in a specialty for your entire damn existence when the people you're working with don't give you a good picture of what it's like.

There are definitely things I can tell I like so far--I enjoy my patients and seeing them in the morning, cracking jokes while I listen to their lungs at o'dark thirty. I enjoy thinking through the process of exactly what is happening to them and why, and learning what there is to be done about it. These are the things I like about every specialty, and they are obviously quite available in medicine as a specialty option. The only problem for now is that I still feel so lost, so incapable of remembering enough to formulate a good differential (read: list of everything that could be causing the patient's symptoms, narrowed down to what's likely based on their history) and I just end up feeling kind of stuck wishing someone could sit down and talk me through what I'm thinking. It's getting better, and I'm getting more confident, but with only 4 weeks to get a feel for this business I'm hoping to pull a lot more out of the next several days.

In which it becomes hard to tell who, exactly, is the crazy one

So. Psych. It's been an interesting month, but I'm kind of ready for it to be over with at this point. I am finding myself incredibly lucky to have been assigned to child psych, because the attendings and residents are lovely and fun and laid-back and somewhat less weird than most of the psychiatrists I've come into contact with (not to mention the awesome hours--left at noon today). The patients, however, can range anywhere from incredibly sad (the four year old who wanted to die rather than see his biological father) to the incredibly weird (a teenager who believes her parents have been replaced by body doubles), to the incredibly frustrating (my patient, who has been depressed for an inordinate amount of time and literally refuses to accept the fact that he's getting better...in fact, continues to claim that he's worse despite the fact that he smiles all the time now).

There are things that I like about psych, but they are, in general, the things I like about most general practice specialties--talking to patients, hearing their stories, and figuring out what is wrong with them by putting the puzzle pieces together (and then of course coming up with the treatment plan). The things I definitely don't like, however, are far stronger. I do not think I could do a specialty day in and day out for the rest of my life wherein people don't, as a rule, get better. Yes, there are many patients for whom we make a big difference, and those are wonderful moments. But for many, we simply listen to their sadness, give them some medication to help balance out their brain chemistry, and send them home to a terrible family and terrible situation that will probably only perpetuate the problem as long as they continue to be sent there. We can't keep the patients forever, and only rarely is there enough of a problem to involve CPS and find a better living arrangement. Instead, we diagnose a lot of patients (especially the younger kids, so often admitted to our service for aggression or other behavioral problems) with "Parental Disorder NOS"* and do what we can for as long as we get to keep them in our care.

Perhaps this is why many people express frustration with internal medicine and family practice--dealing with patients who refuse to get better, refuse to take their meds, wind up back in your office months later for exacerbations of the same problem over and over. Except in this case, it's even more depressing because at least as a family doctor you can place some of the blame on the patient for bailing on their end of the bargain. On the child psych floor, it's almost never the kids' fault that they have a crappy home that has taught them crappy coping skills.

I am incredibly glad that there are people who feel called to be child psychiatrists (or any kind of psychiatrists, for that matter), but I think you might have to be a little bit crazy to be one of them.

Fall

Today, the temperature hit the low 80s, and I sat on my back deck and studied in the sun and the breeze without melting. When I took the dog out tonight, there was just the slightest hint of chill in the air--enough for a jacket, but only just. It's the kind of weather that speaks of apple cider and harvest fairs and backyard bonfires and football games and bold beautiful colors on trees and I love it so, so much. It puts me at peace with the world after the heat and bustle of summer.

Fall has always been my favorite time of year