Time Flies when you're going insane

A Discovery: It is sometimes hard to write about my experiences in medicine.

I thought back when I started this that third year would be a time ripe for the picking of fabulous tales of patients--the hilarious, the heartwarming, the heartbreaking, the annoyingly clueless, etc. Instead, I've been on Internal medicine for almost 3 months and have almost nothing to show for it, in terms of stories that have actually been jotted down on (virtual) paper. It's hard, you see, when you've been at work since 6am and aren't home til 7-8pm, and still have reading to do about your individual patients and about general exam material before you collapse into bed at the woefully "respectable" hour of 9-10pm because it's all going to happen again the next day, to find energy (or just time, for that matter) to reflect upon the happenings of the day. Toss that in with a healthy(?) mix of stressing over the fact that we're halfway through the year and I'm only more confused than ever about what to do with the rest of my life and a desire to spend some kind of time with my husband and my family, and well, writing just goes by the wayside for a while.

Whatever, I hear you saying out there in Internetland, Quit making excuses and just write something already, I've already been here 10 minutes and haven't heard any good stories about insanity or blood and guts. And so, SCENE.

Seriously though, one of the hardest things for me so far about internal medicine is the push-pull over the decision of whether or not I like adults enough to pursue med-peds vs. categorical peds for residency and my eventual career. I enjoyed (for the most part) my time on wards, and was told by my residents that I was very good at it, which got me thinking about the possibilities. On the one hand, adult medicine tends to be more complicated and would require a lot more involved thinking and problem solving on a daily basis, which might be a nice change to just looking in ears and doing physicals all day. Plus, the idea of the kind of continuity an outpatient med-peds doctor could have with their patients--seeing a person from birth to late adult life, for example--is an extremely appealing idea. I got even more into the idea on some of the days I was on an Infectious Disease service recently, as I enjoyed the continuity and complexity involved in working with the many HIV patients we saw throughout those three weeks. On the other hand, this week I've been on an endocrinology service, and I just honestly don't know if I could handle dealing with multiple diabetics who don't take their meds, don't understand their meds and aren't willing to learn, won't quit smoking, etc. day in and day out for the next 30+ years of my life.

I've been going back and forth, sometimes daily, on this debate for the past 6-8 weeks. I have tried very hard (and, I think, at least somewhat succeeded) to be open-minded when it comes to the possibility of medicine, and some days I find myself coming home very excited by it and some days absolutely disgusted. At this point, nearing the end of the clerkship, I feel I'm really no closer to a decision than I was at the beginning. If anything, I'm more confused and, with holiday season burnout setting in in a big way, it's getting harder to tell if the dislike I feel for what I'm doing right now has as much to do with the specialty as it does with my general need for a break. Some days I feel like I just have no empathy at all for my patients, that I just want to escape and go home and have some time to play video games or take a nap or just do NOTHING for a while, and I'm not sure if this is a sign that medicine is not for me or just a sign that Christmas is coming and I'm tired and beaten down by a grueling schedule.

Luckily, I have one more week of endocrine, and then I'm done with adults for a while. After that, I'm doing a week long "career exploration" elective in the NICU, then a week off to study for the medicine shelf exam, followed by two weeks of Christmas break and then Peds in January (for which I'm so excited I could pee myself). Maybe that in and of itself is a sign, who knows? For now I just have to get through the next week.

Of note

Today, I would like to officially note that I have finished wards (and a week of palliative care medicine) and definitely have all kinds of interesting things to say about these subjects that requires much further thought process and time spent typing away, but in lieu of those deep and important matters I will say this

WE ARE GOING TO THE RALLY TO RESTORE SANITY OHMYGODI'MSOEXCITEDICANHARDLYSTANDITOMGOMGOMGJOHNSTEWART!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

That is all.

We'll see.

A classmate asked me the other day how I was liking my time on the wards. One of his other friends, apparently, is loving the experience and genuinely considering internal medicine as a specialty. So it got me thinking--do I like medicine?

I did, after all, come into this rotation excited about the possibility because I have thought about doing med/peds. You know, in case looking into ears all day would be too boring. Also, the idea of being able to follow a patient throughout their life, rather than booting them out the door at 18, is intriguing, especially if you consider the possibility of subspecializing within med peds (for example, a friend of mine wants to do a med/peds cardiology fellowship so that she can treat congenital heart diseases in babies, and then follow her patients through adulthood too). So what's it been like, hanging out on the wards, the front lines of adult medicine? The most I can say, really, is that it's a mixed bag. Perhaps it's too soon to tell.

The Good: As with most general specialties, I enjoy the thought process. Looking at the patient's history, vitals, labs, imaging, developing the differential, figuring out what might be wrong and how you could test for it and treat it. It's a fascinating mystery that unfolds before your eyes.

The Bad: In medicine, once you've figured out the diagnosis and treatment plan, you often end up sitting around babysitting the patient with nothing else to do, either waiting for nursing home placement or consults or confirmatory tests or imaging to come back. I have a patient right now who has been with me for weeks while we try to figure out why he has diarrhea. For the past several days, we have done nothing but order some tests and wait for the results. We're helping him, yes, but not actively so, and that's frustrating.

The Good: You see some really interesting cases. On our call day on Wednesday, we took on a new patient with an incredibly rare type of cancer, one with a rare form of nephrotic syndrome that we're still teasing out the cause of, one with new-onset congestive heart failure, and one with (possibly) a very strange and dangerous form of pancreatitis.

The Bad: You also see some really not interesting patients. Our service is typically filled with patients who are either being treated for a COPD (emphysema) exacerbation, or who have cancer and are just waiting to get their chemo. Not that these diseases are not important, but they don't require a lot of work or thought, much like the original "looking in ears" problem. Also, even some of the interesting patients are, to put it frankly, gross. I have a patient with a chronic bone infection that smells AWFUL. Like, you know what room this person is in because you can smell it from down the hall. In kids, you can look past these things because they're kids and it's cute and you feel sad that they have this gross thing, but with adults, it's just kind of...gross.

The Good: Sometimes, your patients are very kind and thankful and wonderful. I had a patient last week with cellulitis who was effusively gracious about my help in getting him out of the hospital so quickly, and it was moving to have him feel so grateful. It felt good to feel needed and useful.

The Bad: Sometimes, the patients suck. My diarrhea patient (see above) is a cranky, nasty person who frequently tells me what an idiot I am because I ask questions that he has already answered--to someone else. We had another patient on the team whose family screamed at us en masse because we suggested that his confusion might be a result of alcohol withdrawal. I'm sure this is true of many medical specialties, but it's frustrating when you get yelled at for trying to help people.

So yeah. Medicine is interesting, and it's kind of hard to narrow down exactly how I feel about it. I'll have to see how my subspecialty parts of the rotation go. After next week, I spend a week on palliative care service, three weeks on infectious disease (which I'm really excited about), and two weeks on another subspecialty (likely endocrine). If I'm still on the fence, I'm considering doing a week long career exploration elective in the spring in one of the med-peds outpatient clinics to get a clearer picture of what "real life" practice is like. So we'll see.

A tale of three patients

As I'm making my way through my month on the wards at the local VA hospital, I find myself slowly moving out of the realm of "OMG I'M SUCH AN IDIOT HOW DID I EVER PASS THE FIRST TWO YEARS OF MEDICAL SCHOOL" and more into the "ok, I may not know everything we need to do for this patient but I am at least competent enough to reason through what is for sure not happening and discuss with the resident the rest of what might be happening." In other words, yesterday for the first time I admitted a patient and was probably more than 75% correct about what was likely to be wrong with him and how to go about figuring out the exact diagnosis and treatment. I am also starting to feel slightly more comfortable about how to get around the hospital, call consults, talk to families, what my responsibilities are in terms of patient care, etc. It helps, of course, that I have a wonderful new team (for the most part)--one of the new interns is incredibly smart and with-it and also a really fun guy, and our upper level resident is much more approachable and less PIMP-tastic* than the previous one. My comfort level may change with the arrival of our new attending on Friday morning, but I'll hold out for my hopes that the progression of learning and competency will continue.

Today, I was carrying (aka in charge of seeing and taking care of) three patients. These three patients are interesting and challenging in different ways, and I think their stories are a really good representation of what medicine is as a career, a specific specialty, and a learning experience. So of course, for myself and posterity and all three people who might read this blog (Hi, mom!), I thought I'd share.

Patient A was the first patient that I "picked up" last week, who came to us with some pretty nasty diarrhea. A has multiple medical issues, mostly the result of years of rampant and untreated diabetes. A's medical problems are many, but we aren't really doing anything for most of them other than maintaining his current medications while we try to get his intestines under control. When I first met A, he was unhappy with me because I had to repeat a great deal of questions that he had already answered, and his attitude has not improved much since. Each morning that I speak with him, A typically tells me at least once or twice how little I know, how I am not paying attention to him, etc. This despite the fact that yesterday I stayed in his room an extra 20 minutes in order to cut his breakfast food up and assist him in getting ready to eat it. It can be amazingly frustrating to work with a patient who cannot understand that you are trying to help them, and A has been a learning experience if for no other reason than to learn how to do with people who will not be satisfied no matter what, and to treat them with just as much compassion as the kinder, easier patients.

Patient B was my next patient--a kinder, older lady who was recently admitted for a lung problem and was found to have a mass elsewhere in her body that we discovered essentially by accident. She is doing quite well, recovering nicely, but really needs to have the mass removed before it becomes a problem. Our surgeons want to remove the mass in the next few days while her lung function is still doing well, but she refuses to make a decision until she talks to all of her (many) children. We have stressed to both her and her spouse that sooner is better than later in terms of safety of surgery, and while the spouse seems to understand, she adamantly refuses to make a decision. I understand completely that this is a frightening choice that could have dire consequences, and therefore I have worked diligently to not rush B, but simply to present her with the situation as we understand it. Unfortunately, this too can be frustrating as you watch time tick away, betting against the clock that in the two weeks it might take to reach a decision that B's lung function will not deteriorate to the point that there are no more choices available.

Patient C is my most recent acquisition, a lovely gentleman with some intestinal issues. He and his family are sweet and wonderful and easy to get along with, and we will hopefully have a diagnosis for him soon so that he can go home and return to his normal and happy life. I look forward to seeing him every day, and the only challenge he presents is that of remembering how I treat him when I go see my other patients.

Medicine is interesting. I'm not sure if I love it or if this experience will tip me into the idea of Med-Peds over Peds, but if nothing else I feel like I'm learning a lot.

* To "PIMP", sometimes said to stand for "Put In My Place," is the process of attendings or upper level residents quizzing medical students on the intricacies of their patient's disease, some other random disease, or sometimes just ridiculously useless information that the attending or upper level feels the student should, by now, know. Usually comes with a negative connotation, as in those attendings who will continue pimping until the student doesn't know an answer, at which point the attending will ridicule said student for being an idiot who doesn't think his/her job is important enough to study for (even if that student had answered the first 99 questions correctly).

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