medicine · MS-4 · residency

It begins…

Just got back from my first two residency interviews. Scheduling has been a nightmare — I once bought plane tickets for the wrong day — so it’s exciting and fun to actually get started at last. I get to see other parts of the country, other ways of doing things. The view from Ninth Avenue can be stifling at times,* so it’s good to get out and remind myself that there is life west of the Hudson.

I made the wise decision to base myself at my parents’ house in suburban Virginia for interview season. We live about twenty minutes from the airport, and down here I have access to a car, which just makes travel easier all around. It’s great to hang out with my parents more before I disappear into internship.

* I’m being sarcastic. Sort of. New York and me, it’s complicated.

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medicine · MS-4 · narrative medicine · New York

Not done yet

I had brunch with a good friend today, down in the West Village.  She is a literature PhD candidate, about to switch careers and head down the med school route.  And I was telling her about my own near-career switch, back when I was a fourth-year undergraduate so in love with my comp lit thesis that I was about to withdraw all my applications to medical school and apply to lit Ph.D. programs instead.

“But I’m glad I didn’t,” said I between forkfuls of an exceedingly delicious Greek salad with herbed goat cheese. (You can order things like this in the West Village — such a change from the chicken-and-rice cart outside the hospital.) “Because then narrative medicine turned up, and I got to do that instead. I needed that year, but I missed clinical medicine so much.”

“And it sounds like, from what you said about your thesis, that you weren’t done with literature yet, you still wanted to explore.”

“Yeah. And there’s a lot more still to explore — I feel like I just learned a lot of new vocabulary and am barely getting past the surface. Maybe I’ll go back, do a PhD later. But for now… I really need to take care of people.”

I think I’d never articulated that to myself before. Back in November, I started really missing medicine in a very visceral way. I missed the process of history-taking, the back-and-forth, the reconstructed (co-constructed?) timeline of events. I missed the thrill of physical exam findings. (The differentiation between aortic stenosis and hypertrophic obstructive cardiomyopathy is hot.) I missed curbsiding my friends on other services to ask their opinion about xyz, or frantically UpToDating at the nurses’ station. I missed the putting-it-all-together, the generation of a coherent story to pass along to my resident and attending.  As soon as I could rearrange my schedule appropriately, I began volunteering at the free clinic, in order to get at least a little of that back.

There was a re-learning curve at the beginning of this month — I had to look up how to write notes, I had to look up the most basic principles of pathophys, I even once had to look up the normal values for coagulation factors. *shame* But now that I’m back in the swing of things, I feel too excited by it ever to want to leave again. I mean, I helped convince a man to make a lifestyle change that has already dropped his weight by 110 pounds. One hundred and freaking ten pounds — that’s a me. Formerly inside him; like Athena and Zeus. The man now feels better, breathes easier, walks longer. How can you not be excited by that?

So, no, I’m not “done yet” with literature.  But more importantly, I’m not done yet with medicine. As frustrating as the hospital can be at times — one of my patients has been hanging out for a week because of discharge planning problems — it’s also hugely fulfilling. Not necessarily just in the “good outcomes” way, but also in the sheer pleasure of doing something that is of use to other people.

Our conversation moved on to other things, like the evils of the application process (med school vs. residency), the commercialism of Times Square, the sheer awesomeness of Zadie Smith. But that “not done yet” line of K’s lingered in my brain.

Who knew that such profound moments could arise in a slightly hipster joint off Christopher Street?

health policy · medicine · MS-3

Tinfoil hat

The new Crestor label says it may be prescribed for apparently healthy people if they are older — men 50 and over and women 60 and over — and have one risk factor like smoking or high blood pressure, in addition to elevated inflammation in the body…. An F.D.A. advisory committee had voted 12-4 in favor of expanding the usage in December.

-Risks Seen in Wider Use of Statins Like Crestor – NYTimes.com.

AstraZeneca must be rubbing their collective hands in glee right now.

My concern is that this will guide the standard of care (and thus reimbursement, malpractice, and all that good stuff) and that people with neither signs nor symptoms of hyperlipidemia will be labeled and prescribed a drug with a pretty significant risk of muscle breakdown, liver enzyme abnormalities, and Type II diabetes.  Don’t get me wrong, statins are great drugs, but they are not appropriate in the water supply.

medicine · MS-3

Rules for patients

Every hospital should have a copy of these posted NICE AND BIG by the nurses’ stations. (Send the royalties to me, please!)

1. We apologize in advance for the crappy food. We know it sucks.
2. You will be getting blood drawn every morning. This is so that your doctors and nurses can monitor the course of your disease. Don’t refuse your AM labs; you might die. (True story! No one knew the patient had become anemic, and then his heart stopped.)
3. Please be aware that the lab and imaging are understaffed on weekends. It might be a few hours between the time your doctor orders a test and the time transport comes to pick you up. Read a book.
4. If you come into the ED with a runny nose, your wait will be approximately seventeen hours. Don’t whine when someone who comes in after you with an open compound fracture gets seen first.
5. We know when you’ve signed out against medical advice from other institutions. Don’t do it; it makes people suspicious of you.
6. Don’t lie about your history. We ask family to step out of the room for a reason.
7. PLEASE bring a list of your medications. Consider an implantable memory chip in your finger: bringing electronic medical records to a new level!
8. Don’t yell at the nurses, techs, or doctors. We are a fairly passive-aggressive bunch and are very good at “go slow.”

You know, having one day off in 15 is … kind of crappy. We ought to have student work hours, same as residents. It’s a good thing I enjoy medicine, because otherwise I would be truly miserable. Today, because one patient screaming her head off when I got her ABG, and another patient’s brother flipping out at me because the viral cultures hadn’t grown (sorry, I will go to the lab personally and tell the little viruses in their petri dishes to make sure and eat all their spinach!), and the third patient ACTIVELY DYING in front of me — today was somewhat less than ideal. Maybe tomorrow will be better. (I have been saying that every day since January 4.)

medicine · MS-3

Changes everything

I have this patient. Nice guy. Sick guy. On admission, he said, “I don’t want no bad news, doctor.” I promised we would take good care of him.

Last night his cancer markers came back several thousand-fold higher than the upper limit of normal. It’s a bad cancer, what he’s got, very poor prognosis. So today we had to tell him.

We kept putting it off, but finally, after everyone else was tucked in and signed out, my resident, intern, and I went into the room.

Patient was sitting there with his sister. Feeling great, no longer short of breath, no more pain.

It’s so strange, talking to someone who feels nearly 100%, and knowing from a blood test that they are dying.

My resident handled it well. So well, in fact, that the guy thanked him. The sister was sobbing, and the patient was teary, and still he says thank you. That was impressive.

Afterwards, we three went back to the work room and just sat and stared at the floor. Then my intern was paged about another patient’s drop in BP, and we rushed off there.

That’s internal medicine. One crisis after another, and in between, staring at the floor in silence.

medicine · MS-3

Non-compliance

I just finished a write-up for a patient of mine whom I discharged on Friday.  Nice guy. Middle-aged diabetic man, recently out of work, who had been denied Medicaid because he had saved too much money.  Yet he could not afford to pay for private health insurance (diabetes is a doozy of a “pre-existing condition”) and he won’t be eligible for Medicare for over a decade.

His glucose on admission was sky-high.  Turns out he doesn’t take his metformin and glipizide regularly.  Why?  Can’t afford them.  Doesn’t check his fingersticks.  Why?  Can’t afford the test strips.

This is not just some lazy patient, or someone with their priorities screwed up.  When I asked about foot ulcers, he gave me the lecture on the importance of foot care for diabetics.  He made sure to go to his optometrist appointment.  (It was last year; he can’t afford one this year.)  He could use some help quitting smoking, but that’s not unusual around these parts.

We fixed him up, ruled out some of worse sequelae of diabetes, and tried to get him on his way.  We tried to maximize his compliance by putting him on a combined formulation of his home meds.  He needs insulin, but if he can’t afford the fingerstick test strips, insulin is a BAD idea. (Mmmm coma!)  What’s going to happen is this: he’s going to take fewer of the pills to make them last longer.  He’s going to end up in hyperglycemic hyperosmolar state.  And he’s going to end up in the hospital again, maybe with retinopathy or nephropathy or neuropathy (he’s already got numbness and tingling, so it’s just a matter of time).

It’s screwed up.  This guy’s real problem isn’t the diabetes.  It’s the fact that his diabetes can’t be managed because of money and insurance issues.  It really irritates and upsets me that something as peripheral as that — something that I never think about it for myself — is what’s really going to kill this guy.