Mine

This week, I am rotating on anesthesia in the pediatric hospital. Mostly this has been relatively boring, with lots of watching and very little doing. Today, the resident asked the attending if "the medical student" could "bag" the patient--that is, to hold the mask and squeeze the little balloon full of air to simulate breaths in the time period between the patient becoming unconscious and the patient being intubated and mechanically ventilated.

The act of "bagging" is relatively simple: hold a tight seal between the mask and the patient's face, lest any air escape rather than entering the lungs. Squeeze the bag at a rate that will allow for a normal respiration. Hold the patient's chin up to direct air into the lungs. I have seen this maneuver performed countless times, and it looks about as easy as it actually is. An important step, to be sure, but not terribly exciting.

The patient today was a beautiful little girl, about 3. Soft blonde hair, blue eyes. Anxious family members numbering into the double-digits. And the same disability as my sister. When we gave her the medicine that set her off to sleep and the resident handed me the mask and bag for the first time, it was just like I had seen a hundred times--except completely different. As the patient's own respiratory drive ceased and my hands took over, this was more than the movement of air, more than my hands performing learned maneuvers to bridge the gap to the ventilator.

In those moments, as the room buzzed and the attending searched for an IV and the nurses prepared the sterile drapes, that little girl became Mine. She was my sister, my safeguard, given over to my care and keeping. And I breathed for her.

Updates and Interviews

As I sit here at a tiny table in the med school library, chugging away at my appointed 25 pages of First Aid for Step 2 (cardiology...ugh), I am just bored enough to realize that a lot of time has gone by since posting. I finished my AI on the pediatric wards with great success, dove into two weeks at the outpatient clinic where I'll be doing a continuity clinic (one afternoon a week) for the next several months, and took my Step 2 CS exam. Now I am "blissfully" off of rotations until October 24, with the joy of vacation somewhat tempered by the fact that I have to take the written portion of my Step 2 board exam on October 20. I did at least give myself the week or so after the CS exam off and played a lot of video games, though.

CS was interesting--12 "standardized patients" (actors) who present a fake illness which we have 15 minutes to question them about and do a physical exam pertinent to, followed by 10 minutes to write a detailed note on the encounter. And repeat. Mine wasn't horrible, mostly bread-and-butter medicine cases, though there were at least a couple where, upon the leaving the room, I had the unmistakable feeling of being completely at a loss. I think I did well enough to pass, so I'm letting it go. At least with CK (the written portion of the exam), I know how to prepare--standardized tests, bring it on.

I finished my residency application and turned everything in on September 1, and so far I have 7 interviews at places throughout the country (though mostly within a 4-5 hour drive of home). I plan to try to stay at my home program since D has a job and we have a house and our families are here (and hey, it might be nice to think about starting a family before I'm 35), but I have to admit I'm kind of excited to see what other cities and programs have to offer. I sent applications to some very highly-regarded programs and already have interviews to a couple, so maybe I'll fall in love, who knows? I'm excited to do some traveling, if nothing else. Hopefully my bank account won't be too much the worse for wear at the end...

The perks of being a 4th year

Two weeks into my AI on the pads wards and I find that I actually somewhat like being in the role of a resident. I don't mind being at the hospital long hours as long as I actually get to do something with most of my time, and the nice thing is, my residents are pretty good about giving me the leeway. I do my own H&P's, see my own patients, follow-up on cross-covers, check labs, make and give check-out...all things that I couldn't (or could only do in very limited fashion) last year. It's nice to feel that I actually have some legitimate responsibility, even if I can't actually sign anything yet. But even just knowing that my residents trust me to give them an exam or to write the check-out sheet without double-checking it is awesome and reaffirming.

I do have to admit though...perhaps the greatest sign that I'm being treated like a resident is that every time the pager goes off on our call days, I cringe just a little bit inside. Thankfully, yesterday we only admitted two patients on-call, and neither of them were to our hospitalist service (one an epileptic to the neuro team, the other a new diabetic to the endocrine team). So we sat around chilling out most of the day and eating cookies, which is my idea of an excellent call.

Speaking of excellent, I secured another letter of recommendation today, which brings the grand total up to 3 and makes my applications at list a little more complete. Now to take a picture that makes me look somewhat professional and hopefully not too "deer in the headlights on a passport" and we'll be set to go.

Monday Funday

I saw a fundus yesterday, for the first time.

The eye exam has always evaded me, no matter how many times I shone glaring lights into unfortunate patients' pupils--all I ever saw was a blob of red and maybe the occasional vessel, but never any obvious optic disc or macula or other landmark the way you're supposed to.

Yesterday, with the help of a hilarious 6-year old and a very patient doctor who asked me to show him how I did the exam, then corrected all my horrible mistakes and patiently had me repeat them (all while the poor kid sat with my light blaring into his eyes) until suddenly, there it was.

I haven't necessarily become enamored of neuro, but it's nice sometimes to at least know you've accomplished something.

Found

Wow...April? And now it's...July? Well we'll just all pretend that didn't happen.

I really don't have a huge excuse for the giant and obvious lack of documentation of the last three months of my life, other than to say that, as the last post probably makes obvious, surgery was an incredibly difficult two months for me--mentally, physically, emotionally, spiritually, medically...you get the idea. The place I found myself in at the end of the rotation was not a pretty one, and while I expected to bounce back quickly with a celebratory end-of-surgery Royal Wedding Watch Party, getting back to normal was not as easy as I'd thought. In fact, I found myself to be, for lack of a better word, lost. For quite some time. I spent much of my family medicine rotation attempting to find the part of myself that surgery had someone beaten out of me, but in the end it was not something that could be forced. Instead, the defeated and sad little humanist, joy-in-medicine and champion-of-underdogs that lives in my head came crawling back slowly over time and, with the help of excellent friends, a husband with the patience of Job, a lighter rotation that allowed for some restoration of sanity, and a week at the beach, and a little help from Harry Potter, I seem to have found myself again.

So. Enough of all that depressing stuff.

A quick wrap-up of the past three months: I finished surgery and survived all of that. I spent a week in the PICU doing career exploration (saw some neat stuff), six weeks on family medicine (4 weeks out in rural areas in a private practice, where I had a minor career crisis thinking I liked it and was then reminded that day-in/day-out cholesterol checks are NOT. MY. THING.), and a week at the beach restoring my soul. It all went by too quickly. Now I'm officially a fourth year (!!!!), but unfortunately it doesn't feel like it very much yet because I start on neurology, one of the only two "required" rotations of the year. So really, because I'm still rotating through with only my class, we get no senior standing about other students, no special privileges, and aren't doing anything fun or new or interesting like many of my classmates who began the year with electives or Acting Internships. Add to that the fact that we still have to take a test at the end of the month (something practically unheard of in fourth year), and it feels like an extension of junior year. Luckily it's only four weeks, one of which is already over. I'm currently on the stroke service at our hospital, and after this week I get to switch to child neurology which I'm hoping will be much more exciting (or at least a lot cuter).

I'm also in the process of beginning residency applications, which I'm sure will be the source of many more posts in the near future. I've filled out the "Resume" portion of the application already--we can basically start entering everything now but can't turn it in until September 1. The big issue at this point is working on my personal statement--why I want to be a pediatrician/would be awesome at your institution/what I want from you/please accept me I'm awesome in 1 page or less. Woot. In fact, that's what I should be working on right now, but obviously procrastinating here is a much more desirable use of my time. Ah, well...perhaps if I go actually get it done, I can come back here and explain the insane process that is the residency application or something later.

Til' then, it's good to be back.

I've been trying, for the past few weeks, to come up with a way to write about surgery. It's been difficult. The past four weeks have been a more emotional time than I expected, and in the few brief moments of downtime it's hard to reflect on or interpret all of the feelings that bounce around in your head over the course of the 90 hour work-week.

That's basically what I've been up to the past month--I worked for 3 weeks on the general surgery service at a local private hospital, taking call every fourth night. That means that in the average week, I spent one or two 27-30 hour shifts in the hospital, maybe sleeping an average of a couple of hours each time. Some nights are lucky--my last call at this particular hospital we were pretty dead and I got to crash for six hours, but in exchange for that last night on trauma call (we all have to take one night on the trauma team at the local university hospital during our rotation) I stayed for 25 hours and didn't sleep for more than 20 minutes.

I don't particularly enjoy surgery. I expected this coming in--knew that the pace of the OR, the attitudes of the field were not really a good fit for my personality. I've been lucky to work with good residents who have made it more enjoyable than it might have been, but that doesn't make standing still for 6 hours, covered in a hot gown/gloves/mask/hat combo, craning your neck to see something that you will never be allowed to touch all that much better. I also never really want to see another gallbladder in my life.

It's stressful, this feeling of being so totally not cut out for something. I want to do well, to impress my residents and attendings and learn something even if at the same time I want to run away from this rotation as fast as possible once it's over. But I come home at the end of an 11 or 12 hour day, with barely enough time to cook dinner before it's time for bed again and still there is studying that must be done in order to pass the test, still there are things to be done around the house and things that, amazingly, I want to do in my spare time even though there is no time in which to do them. The stress of having to balance all the things that you want and need to do while managing this kind of schedule (especially sleep deprived) is what has made this rotation so difficult. There is no time to rest, no time to sit on the couch at the end of the day and take a breather or think about the day or talk with loved ones for a moment to regain some shred of humanity. That is the toll that surgery is taking on me. Long hours are do-able, boring work is tolerable, even rude or absent team members can be dealt with for a few weeks at a time, but the feeling of running ragged with no chance of ever catching a breath takes a mental toll I wasn't prepared for. (And of course, it doesn't help that I apparently don't do well in hot rooms when my blood sugar drops--add fainting once and having to sit down to prevent fainting another time to the list of stressors--and embarrassment. Woot.) I will be very glad when the next few weeks have passed and I can find myself, can let the tension go and breathe again.

The next 2.5 weeks should be better. I am back at the children's hospital, doing pediatric surgery with people who, while still surgeons, are much more pediatric-minded--more open to teaching, more talkative and friendly, and of course where there are kids and smiles and fewer whiny adults who complain about their need for potato chips the morning after appendectomies. I'm back in my happy place, even if not exactly doing the job that makes me happiest.

But still--April 29th can't come fast enough.

A recap

I'm such a horrible writer.

Much happened in February--so much, in fact, that there was hardly time to process it, let alone to write about it. I worked on a wonderful inpatient team at our local children's hospital, trying very hard to impress people in my chosen field because I hope, next year at this time, to match here for my residency training. It being winter, we were incredibly busy around the hospital, with record numbers of kids admitted, at one point so many patients hanging out in the ER waiting for beds in the regular hospital wards that they had to set up a tent outside to act as a temporary ER because there wasn't enough space otherwise. But yet even with all that going on there were all long call nights where my team sat around in the doctors' lounge watching TV and waiting for many hours to be paged with the news of a new patient who needed to be admitted to our service. Hurry up and wait, hurry up and wait.

As students, we were only allowed to work with patients who were admitted to the hospitalist team--and usually about half of the patients in the hospital at any moment were that, with the other half being admitted to private physicians who came and saw their own kids at the hospital, or were admitted to other specific teams (things like neurology, or GI, or pulmonology). So some days I would have 3 patients to see in the morning, but on some days we would only have 1, or even none, depending on how quickly we were able to discharge people. It made for a very interesting month.

I saw a lot of babies with bronchiolitis and young kids with asthma, exacerbated by whatever recent virus they happened to have picked up recently. A lot of people consider that to be boring, seeing the same thing over and over again without a lot of thinking involved. I was worried, myself, that that might be the case, but the great thing about kids and children's medicine is that there's a lot of turnover--as opposed to adult medicine, where the patients might linger for days, long after you've diagnosed the problem, waiting on lab tests or simply just not getting better, kids tend to heal quickly and leave the hospital just in time to make room for another kid. And even if that other kid has the same diagnosis, they are inherently different and have some other background story and/or cute little characteristics that make it worthwhile to hang out with them and their family, even if all that's wrong with them is the massive amount of snot hanging out in their lungs.

We saw other things, too--babies with jaundice who got put under lights for a few days, a baby with laryngomalacia who was really noisy when he breathed and made his parents (and us) really worried for a while, a teenager with mono that swelled her tonsils to the point of shutting off her airway.

All in all, it was a wonderful month, and very much affirmed my choice of pediatrics for my future career. Unfortunately, now I have been thrown headfirst into the midst of surgery, the most daunting rotation of med school, and have 7 more weeks to survive before I can catch my breath again. Wish me luck.

Goo Goo Gah Gah

Things learned after a week in the newborn nursery:

1. Newborn babies smell fabulous. Seriously. Go smell a baby. You'll be glad you did.

2. Swaddling is more difficult than you'd think. I mean, wrap a baby like a burrito, how hard could it be? Harder than it looks, my friend, harder than it looks.

3. Poopy diapers are not as disgusting as I thought they'd be.

4. Babies = not so breakable. After just a couple of days, you get used to picking them up and flipping them over and whatnot without worrying that their head will snap off.

5. Work is not work when you spend your morning with one hand on your stethoscope and the other on a pacifier.

Connect

I love Peds.

I'm probably beginning to sound like a broken record, aren't I?

Today I saw well babies who needed shots, kids with viral illnesses and fevers whose parents were worried about the possible need for antibiotics, kids with dry skin and coughs and ear infections. I sat and chatted with a very shy just-turned-teenager whose mother began our talk with "He won't talk to anyone he doesn't know."

"Ok then," said I. "Let's get to know each other." I told him my name, where I was from, things I liked to do. I asked him where he went to school, what he liked to do with friends, what he wanted to be when he grew up.

"There. Now we know each other."

And suddenly we know that I like video games just like you like your xbox, and you got a kinect for Christmas, and you might be able to use that to exercise. Now we can identify goals and make changes and try to bring your blood pressure down and get you to stop eating chips after school so you can lose some weight.

I handed out some Benadryl today, and looked in ears and proclaimed them uninfected, but more than that I made connections. And hopefully those connections will result in healthier, happier kids and families.

That is why I love peds.

Love at first sight

My day today flew by so fast I looked up and couldn't believe it was 5:30.

I saw well babies, kids with viruses, a rash, an almost teenager with a weight problem who loved basketball. I chatted with moms and played with younger sisters and was apparently the interpreter phone magnet (seriously, folks, my spanish skills are not good enough for this business).

At first I was nervous, because I'm at the clinic where I did my externship two summers ago, and wondered if my attendings would find me as impressive now as they did then (when they had no expectations--what if now, as a third year, I was just another third year?). At the end of the day, however, the attending I was working with went over my note with me, quietly told me that it was good to have me back, and that my note was better than an intern's. They asked if I still wanted to do peds and were pleased to hear that I was pretty much set at this point.

There is no other way to put it--I LOVE what I did today. I loved everything about it. I walked out of work so happy I couldn't help but smile. It was one of those Aha! moments when you just know. It's right. This is right. I am in the right place, I am meant to do this, and I am good at it. I love peds, and I will make a good pediatrician, and I am so excited for these next two months.

The only problem now will be how to force myself through two months of surgery after this is over. :-)

2010

It's 2011? Really? This seems, for some reason, much more surreal than most other changes in the calendar. I'm not sure what it is, but something about "2011" seems much more futuristic and far-off and other than 2010 or 2009 before it. Or maybe it's just that after 2011 comes 2012 and in 2012 I'll actually have someone put green hood over my head and call me "doctor" and expect me to actually know something.

Either way, with the passing of time and dropping of the ball (even with all of the absolutely horrifying musical acts it entailed--I mean seriously, was anyone else watching the washed up awfulness that was the New Kids on the Block/Backstreet Boys mix last night? I mean, how old did those guys look?) comes time for reflection on what has passed, and what will come. Sometimes it's actually hard to remember what happened a full year ago and remember that it actually was just a year ago that you were doing those things, after all.

So, in 2010:

• January started with Pathology and lots of it. That's most of what I remember--studying for a shelf and being very beaten down with it, and relieved when it finally ended.
• February and March were basically just school, with its studying and whatnot.
• In March, D and I took a fabulous spring break trip to Vienna, Austria as a delayed gratification gift for our first wedding anniversary (the previous June). Even though we were both sick by the end of it, it was fabulous--D's first time, my second, to what has quickly become our favorite city in the world.
• April and May, if I remember correctly, weren't incredibly exciting other than the weather got warmer and school got less difficult. The first weekend of May I took my last final of med school and drove home with the windows down and Sweet Caroline blaring and good times never seemed so good. Of course, the next day I had to start studying for the boards.
• The month of May I spent locked up studying for boards. That is all.
• In June I spent 3 glorious weeks on vacation, including a week in Florida with family.
• July kicked off the insanity of third year, with a six weeks spent on OB/GYN rotation, which I enjoyed somewhat (labor and delivery was fun, oncology not so much). I ruled out OB as a future specialty.
• In mid-August I switched to Psychiatry with child Psych, which I really enjoyed (mainly because of the kids and the people I worked with. We had great hours and a great team, but at the end of six weeks I was bored. Definitely not being a psychiatrist.
• At the end of September I started Internal Medicine with a month on wards at the VA. I had a good team of residents and a scary attending, got along ok, and tried to convince myself I liked it. Some things I liked, others I didn't...I went back and forth for a long time. November I spent on Infectious Disease and enjoyed my HIV patients a lot. December I was on endocrine and decided that Diabetic patients were what probably tipped the scales away from Internal medicine for me.

And now for 2011:

• I get to start my year on a pediatrics rotation, which I am very much looking forward to.
• This year, I will start applying to residency positions, and hopefully begin interviewing in November and December.
• I plan on surviving surgery.
• I will (hopefully) escape for a bit to the beach.
• I will celebrate my third wedding anniversary

Can't wait.

Decisions, Decisions

I just got done spending two weeks on the endocrinology service. I saw some interesting patients with strange things happening to their thyroids and pituitaries and adrenals, but mostly we just saw diabetic after diabetic after diabetic, most of whom did not understand their medications and took up oodles of time with us trying to explain how to get their insulin correct--most of it very futile seeming. During these two weeks, I saw one patient that got me truly excited: an 18 year old who was transitioning to the adult endocrinology clinic from pediatrics, whose parents were exasperated and shocked by the lack of support to be found both in the transition and on the adult side of things compared to peds. The kid had a fairly rare tumor as a child for which s/he received radiation which basically destroyed his/her ability to make hormones. SO. COOL. (Not for the kid, obviously, but for me to learn and think about.)

Also last week we had a career exploration meeting with one of our deans, at which we could meet with the program directors of various residency programs within our own institution and get information about different specialties. I attended the peds info session, met the program director, and found out tons of amazing information from people who were open and welcoming and helpful.

This week I am working as a "career exploration elective" in the neonatal intensive care unit. This morning I didn't do anything but round with the team and it was glorious. Adorable babies, interesting diseases, happy and friendly and welcoming folks who were interested in teaching and are letting me actually see a patient tomorrow. When I walked into the children's hospital this morning, I felt comfortable, prepared, and at home.

In all the craziness about med-peds, it has come down to this realization, more than anything. Whenever I am around pediatricians and talking about pediatric subjects or patients, I am happy. More than happy, really. I feel more and more that it's where I'm meant to be. Having doing endocrine, I just don't think I could deal with patient after patient coming through my doors each day with the same kinds of chronic diseases that aren't being cared for and sometimes aren't even worth advocating for. When discussing program requirements with various directors at the meeting the other day, I realized that if I were to go with med-peds, rotations in the ICU were something I was already dreading, something to be gotten through and survived--while at our meeting with the peds directors, I was trying to get information about how I could set up a rotation this summer in the peds ICU and was SO. EXCITED.

Ladies and gentleman, with the caveat that I must get to my peds rotation in January and make sure.....

I'm going to be a pediatrician. :-)

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

Good thing, bad thing

My new patient is practically a baby--not even old enough for kindergarten. He is adorable and sweet and playful and happy and says "otay" when you ask him how he's doing. He loves his toy truck and playing with bouncy balls. If you spent an hour with him you would probably think he was a completely normal child with a loving family. Until you ask him why he's in the hospital, at which point he'll tell you about how he told his mom that he wanted to kill himself (in a very brutal, detailed fashion) because a close family member has been touching him inappropriately.

Sometimes, child psych sucks.

On the other hand, I got to spend the vast majority of my morning playing with a toy truck, and a bouncy ball, and showing a happy child just what can happen when adults care for you and want what's best for you. We played "What Time Is It Mr. Fox?" in the hallway and colored and watched PBS videos with other little kids and had an all-around wonderful time, when we weren't talking about deep dark horrible secrets.

Sometimes, child psych is awesome.