Hmm, Top Blogs. That’s darn good incentive to keep writing.

After graduating from residency, I took a month off. It was the Holidays, I had finally been liberated from a malignant work situation, I had the chance to be my own man again, to make my own decisions. I thought I could waltz straight out of residency and into any job I wanted. After all, I was a doctor. Young, certainly. Inexperienced, perhaps a tad. But a highly educated and motivated physician. People are always sick, how hard could it be?

Pretty Damn Difficult.

My interests lie in clinical academic medicine. I want to practice, but I also want to teach. Having knowledge is great, but spreading it is infinitely more fulfilling. A fellowship position would have granted me that, but thats a long story most of my old readers already know about and I wont go into it here. So the next best bet was to continue on as a hospitalist, ideally in a teaching hospital.

I tried applying to several, but outside of my training facility, where I will not return, I’m still too young to obtain any kind of academic position. I dont yet have the experience and the breadth of knowledge, I would simply be a glorified resident. Not that I realized it at the time.

No instead it took almost 3 months of unemployment. 3 months of turning down any jobs not in Los Angeles or Orange County. 3 months of thinking I was too good to settle for living in Bakersfield, Palm Springs, Riverside. Thinking that I would start at my dream job, top of my field.

It wasnt a rude awakening but a gradual realization that though I may have graduated, nobody cared or knew the difference. It’s not what you know, it’s what you do. So, I started looking further afield. I still ignored permanent positions in places I couldnt see myself living, but now because I was looking for somewhere to continue to develop my skills while living.

With loans rapidly coming due, and no source of income, I began searching for alternative methods of employment that would pay the bills, develop my skills, and give clinical thrills.

And so I learned about the world of Locum Tenens (latin e.g. to hold the place of) aka substitue/temporary doctoring. 

Doctors leave to have babies, to go on vacation, to move on to other jobs all the time, but patients need to be seen. This leaves clinics and hospitals understaffed, sometimes for only a few days, sometimes for months. While the hospital looks for a replacement, they will occasionally call into a doctor temp agency for someone to help out while they search. Its a good source of short term employment, and all the travel costs including room, board, and airfare are defrayed by the company. Essentially it’s a work vacation. travel the world, treat the sick, and get paid to do it. You just have to keep getting licensed everywhere which takes 6-8 weeks per new facility.

So while I continued to search for my dream job, I accepted my first locums position. A Geriatric Clinic in East Los Angeles where none of the patients spoke any english. It was time to see just how fluent I was, in spanish and medicine, as I began my first real job as an attending physician…

-Dr J

Big updates to cover in this post, so lets get started

First and Foremost, I am no longer a resident physician. The committee who originally placed me in my current straits once again met, reviewed my performance and evaluations of the last 6 months of my remediation and decided I had sufficiently overcome any deficiencies (at least as defined by them) and could be allowed to graduate early, not being required to finish out the full year of remediation.

So for those of you who have followed me since I was just Josh, all the way from a young pre-med, to an idealistic medical student, through the slightly cynical almost Dr J through alternating optimistic and burned out resident Dr J, thanks for being along for the ride and I step into my future role as a staff/attending physician. 

The last six months I have worked my ass off, trying to demonstrate to people I cant stand and have little to no respect for that I am as good or better than the arbitrary standards they have set for me…and i have DONE it. No one was going to shorten my punishment out of the goodness of their hearts, I have forced them to acknowledge me in the only way I can.

A few excerpts from the last several months:

“Dr. D demonstrates clinical skills expected at his level of training. I found his knowledge base to be at or above his level of training as well; most questions I posed to the interns on the team which they could not answer, he was able to do so. Managing his team of interns, he was prepared for attending rounds, aware of the plan for each patient, and provided requested data when interns were unable. When asked to identify deficiencies in the interns for me to address, his specificity regarding this assured me of his adequate oversight over them. His efforts to communicate with patients and their families provided them confidence in our service’s abilities. As an attending physician on R-service I will often receive 1 or 2 afterhours calls from patients’ families inquiring about a patient’s condition, which was never the case with Dr. D as the resident. He demonstrated commitment to teaching as well, focusing on various topics during rounds to review with the interns and, without prompting, volunteered to present an article. On one occasion, a patient of ours became unstable. Dr. D directed the stablization of the patient calmly and with focused attention until her transfer to the ICU. In the time I worked with Dr. D it was evident to me he had overcome the deficiencies prompting his remediation”

“Dr D once again performed in a stellar fashion on this rotation. His management of each patient was appropriate and measured. He was well aware of the developments in each patient’s case, and handled them according to standard of care. He triaged patients well and was able to prioritize work. His documentation was concise, but showed the appropriate level of detail.  Teaching residents and medical students is a priority to Dr D: he puts time aside to do teaching sessions. He actively listens to all team members and tries to take into account the feedback of junior residents and students. I personally elicited the impressions of other team members of Dr D: they felt that he provided excellent oversight, taught well, and respected each and every one of them. Several of those team membetrs highlighted the fact that in this rotation, they received a higher level of quality teaching at the resident level, than on most of their other rotations. 

At the beginning of the rotation and throughout the rotation, I had offered Dr D several minor suggestions. Almost immediately, he attended to each of these suggestions and implemented them well, even better than can be expected. He was very receptive to any advice give, and did not any time, show resistance to being re-directed. Dr D readily admitted fault when necessary; he never shrunk away from responsibility.As on his last rotation with me, he functioned at a level much superior to many that graduated from residency last June. He showed a capacity to function masterfully at an attending level. I strongly believe that Dr D has demonstrated mastery of all core competencies. I am fully aware of the deficits in the past that necessitated remedial work; in my opinion, Dr D has done signifcant and sufficient work to remedy these problems. Hence, I confidently recommend him for graduation as of December, 2012. Furthermore, I endorse his candidacy for gastroenterology fellowship.”

Now they can all just suck it. That said, while my candidacy for gastroenterology fellowship was endorsed, it was not granted. I had hoped, but held realistic expectations. Although I had matched once into this program, the unfortunate reality is that GI is one of the most competitive fields to enter, and I had been amazingly fortunate to obtain a position the first time around. This time, I had no additional research, minimal updates to letters of rec as I could not exit my home facility to do electives, and a black mark against my name from being on probation that anywhere I applied would see. Almost, it is like checking off being an ex-convict on a job application-companies will look, but nobody really wants that risk around their office.

And so, I have achieved half my resolutions-I forced them to allow me to go in time to prepare for a GI fellowship I shant be getting. At least this year. I will take time to think if I wish to reapply yet again with all the baggage attached to my name now, or If i rather will enter the workforce, and begin my practice as a outpatient doc or hospitalist, start repaying my loans and living the life the universe has deemed fit for me.

While the whole situation has been terribly frustrating, I at least have the knowledge that I did make it once…ergo, I’m good enough, I’m smart enough, and gosh darn it, people like me! 

My official date of graduation is Dec 31st although my clinical duties the remainder of the month are mostly restricted to a couple clinic days and administrative educational activites. On Jan 1st, I begin the new year as a new doc, a new person, and who knows, perhaps we will cross paths one day. That said, the adventure will continue as I learn my way through the recruitment process and the first fumbling steps of a new attending, and I hope you will all still come back for regular visits with this virtual doc

-The Real Dr J

There’s always an element of mystery about a hospital.

Patients will enter with a vague sense of uncertainy and unease, a nagging certainty that something is wrong but they dont know what. Having moved beyond their problem solving abilities, they turn to an authority, the physician. For some, the answers come easily: You have disease/condition x, the treatment is drug y which you have seen on tv, take it for 2 weeks and then you will be cured.

For others the suspense drags on: muttering in the hallways outside the patients room, increasing numbers of specialty consultants, treatment changes day after day. Oftentimes a mere 10 minutes to speak with the physician, hoping to obtain the medical equivalent of a facebook status update-Bob’s weakness is improving, Jack’s liver needs to be replaced, want to share your lab results with friends and family?

And through it all, the doctor is seen as the man behind the curtain, the conductor of a veritable symphony of nurses, techs, equipment and labs. After all, solving mysteries is what we do, isn’t it. CSI: You. Feeling weak? check the blood. Vomiting? scan the belly. Fevers? get a lumbar puncture and start some vancomycin. In internal medicine, the deepest satisfaction often comes from solving the mystery of you. Many treatment are simple enough once we have an idea of what’s going on. 

Coming in to the hospital every day, wondering what you will see, when you will figure it out, can it be beaten; it can be exciting for quite a while. But eventually all heart attacks, all strokes, all tumors look the same. The answer to diabetes is always better sugar control, the eventual outcome of cirrhosis is always poor. So how do you keep the magic/mystery alive?

By focusing in on the details. Yes, every heart attack gets treated with aspirin, but Cindy’s ischemia was caused by cocaine, Ethel’s by clogged arteries from an all bacon diet, and Ricky’s by being shot. Identifying and treating the condition makes you a good doctor. Remembering the person makes you a great one.

Which one am I? Which will I become? 

I guess there are a few mysteries left to unravel after all.

You Knew this was bound to happen between the late nights and high stress of night float, right?

I present the Night Float  version of Carley Rae Jepsen’s Call me Maybe

If you are really lucky, I will make a music video version

[verse 1]

you were admitted last night

gave your family quite a fright

with those low electrolytes

oh yeah and by the way

chest pain and shortness of breath

coughing up blood right and left

looks like you’re approaching death

it’s time to save the day

bp aint holdin’

get those pressors flowin’

add some vanc and zosyn

oh my god he’s coding baby

[chorus]

hey I just met you

and this is crazy

but i’m MOD

so page me maybe?

you’re feeling weak now

and you’re eighty

need blood transfusions

so page me maybe

hey, i got signout

that you are crazy

here’s some ativan

so page me maybe

there are no other docs

that dont phase me

I’m the MOD

so page me maybe

[Verse 2]

you took your time with the call

patient in 3 had a fall

now she’s not speaking at all

let’s get a head ct

that guy with the DKA

he hasnt eaten all day

he’s signing out AMA

oh well less work for me

your heart rate’s slowin’

get that o2 flowin’

it’s another code and

guess i wont be sleeping baby

[chorus]

hey I just met you

and this is crazy

but i’m MOD

so page me maybe?

low urine output

place a foley

surgical patient?

then call SOD

hey, when i met you

you looked plaguey

place a ppd

then page me maybe?

there are no other docs

that dont phase me

I’m the MOD

so page me maybe?

Before you exit from this life,

fill out this polst form

change your code status

sign here on this polst form

Before you exit from this life

change your code status

you’ll be the gladdest

dnr status

[chorus]

you just don’t look right

sepsis lady

you need central lines

so page me maybe

hey I just met you

and this is crazy

but i’m MOD

so page me maybe?

there are no other docs

that dont phase me

I’m the MOD

so page me maybe?

Hey all, so I am in the midst of finishing up my application to GI Fellowship and would greatly appreciate your help in reading and critiquing my personal statement. Please feel free to be as brutally honest, detail oriented, grammar nazi or what have you as you want. Anything that can make this better and help me get my fellowship is well worth any potential hurt feelings you think you might get. Positive feedback appreciated too of course =)

“I didnt know people could turn that color” I thought to myself as I looked at the patient in bed 32b, his skin a diseased shade of yellow I had previously only seen in the spice section at my local ethnic market.

I love gastroenterology because it offers me the best of all worlds: Procedures such as egd,ercp, and eus to not only diagnose but often immediately treat GI problems; and continuity of care with chronic diseases such as hepatits or inflammatory bowel disease where I am able to follow and build a lasting relationship with my patients.

-Dr J

My patient got paid in goat.

Let me back up for a moment. I am back on wards, overseeing interns and calling consults and all the associated workflow that comes with the rotation. I am at the beginning of my six months of probation, working under people I cant stand, spending every waking moment trying to prove to them that I dont make any mistakes in an effort to graduate and return my life to it’s original track, achieving a fellowship in gastroenterology, preferably in Chicago. I am in the midst of re-applying for said fellowship, scrounging up letters of rec, attempting to publish a case report or get involved in a research project, and pounding my head to come up with a new personal statement to bring back to the program who originally accepted me; show them how much I have grown, and play off this series of unfortunate events as an advantage. All said, I have rather a lot on my plate at the moment…now back to the story

One of my recent patients is a family practice physician who runs a donation clinic out in unnamed city nearby. The clinic will take medicare and medical, but due to the population this physican serves, will also take anything else patients can afford to spare. The physican always jokes with his patients that he takes cash, card, concert tickets, cookies, chips, or chickens, whatever the patients feel is a fee for service rendered. Mostly he gets food for the office staff: tamales, vermicelli, eggrolls, tacos, etc.

One day however, a patient calls him up and asks if he is at home. He responds in the affirmative, and they say they will be over in 15 minutes with a goat for him. Thunderstruck, and yet secretly thrilled, he informs his wife, who kindly tells him he is out of his ever-loving mind. However, when the patient arrives shortly after, they tell him they are moving away, and remembered how he always says they can pay him in farm animals, and this goat is “too cute to eat” so they figured they would give it to him.

Well one look at the goat, and in fact, it is too cute to eat, so a doc in downtown LA now has a goat in his backyard that he doesnt know what to do with. I am helping him look for a good home for the goat, as he has told me his gardener offered to take it, but would eat it. Apparently the gardner has no problem eating cute animals.

I came home, and thought to myself, I would like to be that doctor some day. Have my own practice on the side once a week, just for kicks, and maybe get paid in goat.

After all, my current backyard is big enough for chickens…hhmmm, I wonder…

-Farmer J

I am backlogged up the wazoo with post ideas, so I am going to vomit one or two out and then hopefully blog em as I think em:

1) Histories

If you ever wondered why the doctor presses you to give more specific information, it’s because we don’t want our dictations to sound like this:

Mr. Smith is an old man with pain everywhere for an amount of time he won’t tell me. He rates his pain as “okay” out of 10, can’t describe it, and says it is associated with a funny feeling in his legs. He takes a medication for the pain that starts with the letter R. He is not sure of the dose. He went to an emergency room somewhere for the pain a while ago and they took X-rays and gave him a shot of some kind, which didn’t help. He had an MRI ordered by some doctor. He doesn’t have the MRI or report, but he thinks it showed a disc

This is how every one of my histories starts, and most of the doctor training is learning how to guide your questioning and direct the pain into something more like this

Mr Smith is an 70 year old gentleman with a history of lower lumbar pain for>5 years as a result of a slipped disc from a skiing injury taken with his grandchildren in 2004. Recently after falling at home, he has noted increased pain sharp in nature radiating down to his legs bilaterally. This feels similar to his exacerbations of his herniated disc in the past, and he went to an ER 1 month ago where imaging confirmed herniation, for which he was evaluated by ortho and given norco until follow up with spine surgery

See the difference? That’s 3 years of training right there. btw mr smith is entirely fictional

2)Ethics

I cant believe this actually happened. Via FB message and then chat no less from someone I havent seen since my highschool reunion but is on my friends list because, internet.

“Hey, I know we haven’t talked in a while, but I just thought I’d call to catch up.”
“Oh. Okay. Great. What’s up?”
“I don’t know. Not much. You’re still doing the whole doctor thing, right?”
“Yep. Third year of residency. Almost done.”
“Great. So you already have a medical license and everything.”
“Yes. That is something I have. 
“Yeah, yeah. So, I was just thinking, you wouldn’t happen to be able to prescribe me some Ambien, would you? I’ve been having a lot of trouble sleeping.”
“Uh, you should talk to your regular doctor about that.”
“I don’t really have one. I just thought this might be easier.”
“Easier, maybe. But I really can’t. I’m not your doctor.”
“I don’t really have insurance anymore.”
“Free clinics…”
“Come on, what kind of doctors are working at free clinics?”
“Doctors like me. Residents. I think it’d be fine, especially if you’re not working and can wait for a couple hours in a waiting room.”
“Ugh. That sounds terrible. What if I pay you– not like you’re selling drugs or anything like that, but if I’d have to pay a doctor anyway, I may as well pay a friend what I’d pay.”
“Not from me you won’t.”
“Come on. Be a friend?”
“Not a cool thing to want me to do, I promise.”
“Oh, well. Figured I’d try. See you around?”

I mean, really? We dont talk for years and then you hit me up as a dealer? I though I would be further into my career before that started happening

3) Fun

Oh clinic Patients, how I have missed you

“If I use the nicotine patch and the contraceptive patch, do they cancel each other out?”
“No.”
“What if I get them confused?”
“Don’t.”
“If my boyfriend uses condoms while I’m using the patch, do they cancel each other out?”
“No.”
“My friend has some kind of ring she uses as birth control. Can I get that even if I don’t know my ring size?”
*facepalm*

my schizophrenic patient is telling me she doesn’t want to take her very much necessary medication, because she doesn’t like how it looks.
“If you don’t take the medicine, you’re crazy.”
[long, awkward silence]
“I didn’t mean it like that.”
“No, it’s okay, I am crazy. I know I’m crazy.”
“You’re not crazy, you have an actual illness. I didn’t mean to call you crazy. The medication is important.”
“Well, if you think I’m taking it, you’re crazy.”

Really these should all be separate posts, but it’s just easier to stuff it into a super special post for you guys and then try and get back on track with multiple mini posts as they occur. Thank you, that will be all

-Dr J

I Talk a lot about what it’s like being a resident on here, and even more about the hospital behind the scenes that you dont see. 

But that got me thinking, what is it like behind the scenes as a patient? I spend a ton of time in the hospital and yet I am rarely sick enough to require it. But some patients seem to really enjoy their hospital experience while others remain miserable the whole way through. So what are some steps you and your loved ones can do to improve your hospital stay?

1. Bring something to do: a laptop, a book, a crossword puzzle. You are going to be left alone in your room a lot, and believe me counting the cracks in the ceiling gets old quick

2.Bring your own pillow. just trust me on this one. Comfort and sanitary issues of hospital pillows aside, the best thing you can do when you are sick is rest, the best way to rest is on a comfy pillow

3. Have an accurate and updated med list. If you are older than 50, you should have one of these on you at all times…especially in this electronic age, your doctor may only have a list of every medication you have ever been on, not just what you are taking now

4.Write down all your questions early.  Your doctor will only come to your room  once a day  (because they only get paid by Medicare to come once in a day) and any unanswered questions will have to wait until the following day.

Do you feel weird when your doctor is the same age as you?

There is always a slight amount of awkwardness on my part when I have patients my age in clinic. Not something I feel when patient are 5 years my junior, or 20 years my senior. A brief eye opening moment, of there but for the grace go I. Two 30 year olds walking into a room, one accepting the absolute authority of the other.

It doesnt affect my care, my treatment, or anything I do, but I guess I just have more a sense of awkwardness. If i were in their position, would I accept me as a doctor? Who is this guy to tell me how to live my life?

With our older patients, my fellow residents and I act like we know what it’s like to have to take 10 pills a day, or how easy it should be to lose weight and cant understand why patients aren’t following our instructions. With our younger patients, we have crossed the line into adulthood, joining the vast cabal of “grown-up” knowledge giving us our authority and right to tell them to have safe sex, stop smoking and the like.

WHen someone walks into the room who is my age, I always feel like I have been caught in the act. As though they are gonna call me out and be like, well you had everyone fooled for a while, but time to give up the game. Cmon, lets go grab a beer or something and you can tell me how this whole doctor thing worked out.

I wonder, will I ever settle comfortably into the white coat?