I’ve been debating for a long time whether or not I should write about this. But the issue’s come up over and over, and I keep dancing around it, and then I blurted it out on the phone, so then I figured, what the hell.
So I had this patient…
Category: MS-3
I should be happy. Yesterday I took my last shelf exam ever. I never have to go to the OR again. I have five days off before starting my sub-internship. By all accounts, I should be thrilled and enjoying this sudden free time.
Yesterday was fine — end-of-the-year class party (on a boat!), birthday dinner and drinks for a good friend. I got a good night’s sleep for the first time in weeks. My apartment is (reasonably) clean in preparation for my mother’s visit. So why do I feel so … blank?
I felt this way before: after taking the MCAT, after turning in my undergrad thesis, after hitting “submit” on Step 1. The sense that this major part of my life — Third Year — is suddenly and anticlimactically over, and I don’t know what to do with myself.
The other day, I was on the train when there was a commotion at one end of the car. I couldn’t see clearly from where I stood, but someone kept saying, “Mom? Mom?” and someone else gave up their seat. Then a third lady called for a doctor. No one moved. After a minute or two, a fourth-year and I went up to the end of the car to see what we could do. As we pushed our way through, all I could think was, “I don’t have my stethoscope, what can I do?”
The patient was an older woman, sweating profusely but conscious and speaking in full sentences. No apparent distress, as they say. She denied chest pain or shortness of breath, mumbling instead something about how she hadn’t had enough water and that she had a kidney problem. She had a water bottle in her hand. So we walked back to our seats, reassured.
But I can’t get it out of my head — what if it had been something serious? What if she were still down when we found her? She had a pulse and was breathing, so CPR would have been foolish. I could rattle off a long list of the causes of loss of consciousness, but I can’t tell you what to do about any of them in the field. Stroke? Get ’em to a hospital so they can get IA tPA. Seizure? Get ’em to a hospital so they can get diazepam. Massive pulmonary embolus? Get ’em to a hospital so they can get IV tPA and a drug-eluting stent.
I’m almost done with my medical education, and I know how to do a million-dollar workup, but I don’t know how to save a person’s life.
These existentialist thoughts have been made possible by Procrastinia, Muse of Students Everywhere, and by contributions to your PBS station by Viewers Like You. Thank you.
It’s been a while. I’m sorry; peds and surgery have taken over my life. More on them later, but for now, a little appetizer:
The other day, I held a human heart, beating, in my hand. It was bigger than my fist and finely slippery, like satin on bare skin. The aorta throbbed away just cephalad. Think of it — a human heart! Not brown-gray like my cadaver, nor red like cartoons. Yellow, bright neon smiley-face yellow, shout-to-the-world yellow, lovely protective pericardial fat yellow.
Clamp clamp clamp, suddenly tubes everywhere, a word from the attending and dark blood flew through the tubes to the machines behind us, a second later bright red blood flew back, all with the precision of model trains. I looked down into the body cavity again: the heart just lay there. The lungs began to shrink away.
We did the graft — two coronaries; this was a sick guy. Microanastomosis through microscopes, beautiful perfect whipstitching. Another word from the surgeon and the tubes came out and the heart, which had lain there most obligingly, began to contract. Just a little at first. The attending prodded it with a finger and it angrily kicked back. He pulled out the paddles and shocked non-chatantly, as though it were merely a formality. That started the heart galloping. We closed (and by we, I mean the surgeon said “Have you sutured before? Go for it!” as he scrubbed out and my classmate and I closed this man’s midline sternotomy).
Today, I held a human heart, beating and then not and then beating again, in my hand. I begin to see why people like this field.
The doorknob
The more I go through this rotation, the more I realize that primary care is not for me. I am tired of being everyone’s mother. Half of this stuff is common sense. Low back pain? So sit up straight. Trying to lose weight? Take the stairs. If you want to show me the gross fungus on your toenail, don’t paint them before coming into clinic.
Sure, there are legit issues to sort out, like the kid with a history of hydrocephalus treated pharmacologically (??) who now has chronic headaches after Valsalva. We sent him for a head CT, and I want follow-up, but he won’t be back until after I leave. He’s the exception. Most headaches I’ve seen are due to eyestrain. Why are you reading in poor light? Do you want to go blind? (I told you, I’m turning into everybody’s mother.)
Today, there were a lot of doorknob questions. You know the type. History taken, physical done, assessment and plan formulated in your head, about to go present to the resident/attending. And when your hand is on the doorknob and the words “Voy a hablar con la doctora y regresamos pronto” on your lips, the patient goes,
“Doctora, una pregunta.”
It’s never una sola pregunta. It’s several. Once, I had a history of depression come out of nowhere. (I admit, I don’t generally ask psych symptoms on the review of systems, unless I suspect or there is known psych history — so that one was my fault.) Point is, the doorknob questions are the worst, because they are almost always serious. And they set you back ten, fifteen, twenty minutes. And then your next patient, having waited an hour to see the doctor, wants to take an hour themselves to discuss their chest pain, shortness of breath, and leg edema (oh, three cheers for heart failure!)
I don’t know what to do about these patients. I don’t want to blow them off, because often the doorknob issues warrant attention, sometimes even changing the differential, but at the same time, I cannot spend 45 minutes with each patient — it’s not fair to everyone else, and I’d never leave clinic. Tough call.
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 , 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.
It passed!
I have to say, I am pleased at the passage of the health care bill. It’s a good first step in this long, hard struggle of health care reform.
I’m not convinced by the argument I have heard so many of my classmates make, that reimbursements will necessarily go down, or that a government-run option will by definition be inefficient. Private insurance companies spend 30% of their income on administrators. Medicare’s overhead is in the single digits. That sounds pretty damn efficient to me.
Behind the curtain
Just finished my week of anesthesiology, and I have to say, there is a lot more going on behind the drape than I had thought. All those beeps and blips and careful titration of meds. There is a lot of medicine in anesthesia, by which I mean a lot of monitoring and thinking and pathophys and pharm — in other words, all we do on the floors. Frankly, that’s a lot more exciting that whatever is going on on the surgical field.
This is a great part of the fun of third year: discovering the way your personality clicks with the culture of the specialty.
I miss patients
One of the things I dislike about surgical subspecialties rotations is that because they are only 1-2 weeks long, you aren’t following patients the way you do on standard 5 week rotations. There’s really no point. So we float along, watching a few surgeries operations*, doing time in clinic. There’s no continuity, though, unless Serendipity comes along and waves her magic wand. By pure chance, my former medicine patient became my pre-surgical clinic patient, and then I reorganized my schedule to be able to see his surgery operation**. He was a sweetheart of a guy, very jokey, loved messing with me by asking inane questions. (“How does the ear work?”)
Aside from that, though, it’s a lot of wandering around without any responsibility or investment in patient care. I scrubbed to retract on the removal of a parotid tumor, which is a very delicate operation because of the facial nerve running right there. It was interesting to see, but I’d never met the patient before her surgery operation***, and I never saw her post-op (she went home later that day, I think). So….
Bottom line: I miss having patients. I don’t know what I’m going to do about that next year.
* One of my older and wiser friends says “Surgery is a field; the procedures are called operations.”
** But I think this is trying too hard.
*** Yep, ridiculous. I’ll go back to being uncouth.
Review of systems
The review of systems is a weird part of the interview that I haven’t quite gotten my head around yet. Basically, it’s a series of head-to-toe questions that act as a grab-bag for “anything else going on.” In theory this sounds great, and sometimes you do pick up something relevant in the ROS. For instance, my clinic patient who endorsed bleeding gums and easy bruising, who coughed up large clots of blood after his laryngoscopy.
Mostly, though, the ROS is a minefield. If you ask someone if some part of their body hurts, chances are they will spend about 30 seconds considering and then often as not say yes. Which means you have to spend the next several minutes exploring their head pain, neck pain, chest pain, abdominal pain…. Sometimes we get so caught up in teh review of systems that I forget what the chief complaint is.
In the inpatient setting, there is a little more time to address and think about the ROS. In clinic, though, there are so many people to get through that it hardly seems worth it to actually go through the checkboxes. But then skipping hte review of systems, or checking off “Normal” for everything, is poor care, even I know that.
My attending today, on this dilemma: “There is reality, and then there is what actually happens.”
Off-White Coat 