What you say: "I take my pills almost every day."
What we hear: "I almost never take my pills, and probably don't even know where they are-- if I even filled the prescription to begin with."

What you say: "I think I followed up with the specialist, yeah."
What we hear: "I did not follow up with anyone, and only now remember that I was supposed to."

What you say: "You told me not to eat anything before I came in, so, yeah, I basically didn't eat anything."
What we hear: "I had breakfast, but I ate it quickly."

What you say: "I probably don't exercise as much as I should."
What we hear: "The walk from the parking structure to the clinic is the longest walk I've taken since my last visit."

What you say: "Do I need to get that test done today, or can it wait?"
What we hear: "Am I actually going to drop dead on the way out of the clinic, or can I forget all about this, forever and ever?"

What you say: "But what I really want to talk about is this other symptom that I've been having for the past twenty years, unchanged."
What we hear: "Here is an irrelevant distraction I'm going to mention, that's been going on so long that if it were important, it would have killed me already."

What you say: "And I read online that--"
What we hear: "I am now going to prove that I have access to the Internet."

What you say: "No, that's okay, I'll call for a follow-up appointment."
What we hear: "Goodbye, forever."

Doctors are a lot like mutants...there are a lot of us out there among you, we each have our own special abilities, we feel like no one but others in our situation can understand what we have been through and we are feared and distrusted by a lot of the general public who seems to think we have abilities beyond human ken

Sadly the resemblance ends there or I would be liquifying stuff with my mind all day long. Of course just like Professor X's gifted, we all went through a special school where we learned to develop our burgeoning abilities as well. For some of us the mystique didnt last and we left for greener pastures. The learning process managed to turn others of us into beasts, although we manage to retain some of our human nature. The rest of us may have remained unchanged on the outside, but the havoc within us could lead to screaming banshees at any moment and magneto could...you know what? I think I lost my metaphor somewhere, let me know if you see it around.

More to the point, July 1st is the medical new year.  Medical interns begin their journeys into the real world of clinical medicine, journeys that started during medical school but become much more real when they sign their own orders in a chart. This is the first week for all these new interns. So New interns, I was once in your shoes, and will be again when I start fellowship next year. Here are a couple things to keep in mind:

1.Embrace your fear.  You have good reason to be scared.   You are directly responsible for the lives of others.  These others are very sick, or they wouldn't be in a hospital.  But remember that you aren't alone.  Your colleagues can and will help you, and you can help them.  Support each other.  

2.Never be afraid to ask for help, but when you call, have your information in hand; anticipate questions.  If you don't know what to do about a cardiac dysrhythmia, make sure you have an EKG and have ordered some labs before you call the cardiac fellow.  It will save you time and embarrassment, and will get the patient help more quickly.

3. Sleep when you can.  Sleepiness harms both you and the patient.  I cannot emphasize enough the value of sleep.  Go to bed early, nap if you can.  If you're too tired to drive home, don't

4.There is not a single tone on your pager that will not make you hate all humanity at 3 in the morning. Sorry.

5. You now  live behind a magic curtain of people’s expectations and perceptions. You are more than just you now, you are a symbol...like Batman, or Captain America. Try to live up to it, but give yourself some secret identity time too.

-Dr J, superhero at large.

In just a few days I will begin my final year of residency. Starting once again, on night float :-/ Ah well, what can you do. It seems strange to think I have been jotting down intermittent thoughts here since my pre-med days, all the way up to now, when I will be finishing up residency and beginning a fellowship. I look back at myself and sometimes wonder how I had the dedication to stick it through. There is never any hint of doubt in my posting that being in medicine is what I wanted to do, although there is lots of doubt about the path I thought I could or would take.

And yet despite all that I made it. Muddled through step 1,2,3 of the usmle, obtained my medical license, my DEA card, my NPI number, more letters after my last name than anyone really cares about and I still have another 4 years of training.

That said, This friday, when I start as an r3, no matter how stressful any given patient or night may become...

...I made it.

Video link courtesy of one of my interns

-Dr J

"I'm leaving the hospital."

"Sir, you have pneumonia. You need treatment."

"Well, I'm not getting it here. You had me waiting in that room for hours."

"That's your hospital room. That's where you're staying to get treated. It's not a waiting room, you're not waiting for anything."

"You just left me in there to die."

"We left you in there to sleep. You pulled out your IV, which we were using to give you medicine-- I don't know what you want us to do."

"I certainly don't want to be locked in some room like a prisoner."

"You're not a prisoner. We're just trying to treat your pneumonia."

"My family doesn't even know where I am--"

"I spoke to your daughter. She knows where you are."

"Well, they didn't come visit. So they don't know where I am."

"They know where you are. I'm sorry they didn't come visit. Maybe they're on their way."

"Well, it's too late. They're not going to find me. Because I'm leaving."

"It's not a good idea to be walking around with pneumonia. You'll make yourself sicker."

"Or I'll go somewhere else. I don't want to give you my hard-earned money."

"Sir, you're on Medicaid, it's not your money."

"I don't even want to give you the government's money."

"Okay, well, if you want to leave against medical advice, there are some forms you have to fill out."

"I'm not filling out any forms."

"If you want to leave, you need to sign some forms."

"I'm not even going to tell you my name."

"We know your name."

"Like I'm a prisoner."

"No, like you're a hospital patient, with pneumonia that needs to be treated."

"Then treat me."

"That's what we were trying to do."

"No one even gave me dinner."

"They're on their way down the hall right now."

"Is it good?"

"I don't know. I don't eat the food."

"I'll stay for dinner. But then I'm leaving."

"Okay, sir. If you could please go back to your room, there are other patients I need to see."

"The dinner better be good."

"Okay, sir."

9am. The alarm goes off.

Of course, I have already been awake since 6am. But the alarm is not to wake me up. It is a reminder to check the computer for the results telling me the future path of my life.

Nothing in my email...I begin to get a little nervous.

I log in to NRMP. I check the results

...

I MATCHED!

Starting July 2012, I will begin my training as a gastroenterologist at cook county chicago. 

For a while there I was worried. GI is one of the most competitive subspecialties in internal medicine, exceeded only by Cardiology. You have to be among the top of the top to secure one of the very few available positions. And despite applying to 10 odd programs, I only recieved 2 interviews. And of those interviews, each one will evaluate a total of 5-600 applications, offer 30 interviews and accept 2-3 fellows a year.

I managed to pick both my location and my specialty. An impressive feat, and I couldnt be happier that I will spend the remainder of my career doing something I love and find endlessly fascinating.

Momentous enough that I felt like coming back to xanga to share with you all

-Dr J (almost Dr GI J.)

On yet another day of continuity clinic, I was expecting more mundane blood pressure and diabetes follow ups, another visit from my fibromyalgia patient, and possibly some genital related question. All in all, pretty standard fare.

Hmmm...25 year old here for yearly physical, no past medical history. Oh good, I figured, this wouldnt take long...go in, listen to heart lungs poke around stomach and reflexes, send him on his way with a clean bill of health.

Pt: Oh doc, I had a couple questions while I am here, the last doctor wasnt really able to answer them to my satisfaction and just sort of brushed me off.

Dr J: alrighty, fire away...

Turns out that the patient had had a 15-20 pound weight loss in the last two years, most likely because everytime he ate anything, he would throw up about 20 minutes later. He said his previous physician 2 years earlier told him he was a healthy weight and not to worry about it. Now, he was still a healthy weight, but I asked him, if he threw everything up, was there any pain or difficulty with swallowing, and he denied any. Then I asked him what foods if any he was able to keep down...and he mentioned his diet consisted entirely of fruits and vegetables

At this point, the hamster wheel in my head began to spin...

Upon further review I learned that the foods which tended to make him sick following their consumption included spaghetti, rice, milk and cereal, and occasionally alcohol, specifically beer

Noticing a pattern? all grains. all gluten containing foods.

So I sent him off to GI after ordering a comprehensive celiac disease workup including an iron panel and IgA antiendomysiall antibody and Iga antitissue transglutaminae. In earlier times, an antigliadin antibody would have been ordered as well, however that has been found to have a lower sensitivity. It came back positive.

What makes this patients case so exciting (at least to me) is that he had no family history of any digestive diseases, and was from an ethnicity in which this particular disease is fairly rare and unlike the majority of my celiac patients who show up with the diagnosis already made, this was somebody who had absolutely no clue what was going on with him.

Sure it was a fairly textbook presentation in terms of symptoms, but had he not seen me, he could have gone on for who knows how many years with the same problem, just being brushed off until some other doctor picked it up on a whim.

My patient

My knowledge

My Diagnosis

It was one of those moments that helps to remind me why I went into the field.

I havent done anything educational here for a while. No, it has just been comics, and occasional mentions of my travels (still have a ton of australia posts to do) or my love life (spending time with girlfriend takes precendence over updating the intarwebs). Medicine works its way in every so often as well.

SO today, I am going to learn you all good about some handy dandy food products you can use for medical conditions. Please note, none of this constitutes actual medical advice, as for all you know I could be a cabbage farmer in Siberia (bUy our cabbage, it makes you strong like bull!)

Cranberry Juice:

This is the one you probably all know about already, but a recent review of the medical literature shows that cranberry juice may actually be helpful for preventing UTI's in woman who expereince them recurrenctly

Coffee:

Caffeine is structurally remakrably similar to theophylline, an old-timey treatment for asthma little used today. Although we have access to beta blockers and inhaled corticosteroids, should you be on vacation and suffering from an asthma attack with no nearby hospital and no meds on hand, downing as much coffee as you can should help ease your breathing while en route to proper medical care

Honey (yes dear?):

Yet another cochrane study although of much lower quality showed that honey may be better than placebo in relieving the pain of partil or full thickness burns...so next time you have a sunburn, dribble some honey on it. Also effective? the tannic acid in lipton tea bags...slather yourself in a little english breakfast and watch as that burn fades away!

Vinegar:

In one that is close to my heart, especially during the summer season, vinegar should be liberally poured over any jellyfish stings, as it will prevent the undischarged stinging cells from firing. Contrary to popular belief, urinating on it will not work and will just embarass you and whoever you are urinating on...unless you are into that sort of thing, which is an entirely different problem.

Bacon!:

Myiasis is tissue infestation by fly larvae (Order Diptera). There are different types of cutaneous myiasis, including wound-infestation, migratory and furuncular. Furuncular myiasis results from the fly larvae penetrating the skin where they feed in the subcutaneous tissue. The larvae still need to pop up for air now and then, so seeing a wriggling white thing with black “eyes” (respiratory spiracles) poking out of a skin lump is a dead give away. There are two important types of fly that cause furuncular myiasis. The human Bot fly (Dermatobia hominis), found in Central and South America, and the Tumbu or Putsi fly (Cordylobia anthropophagia) from Central and Southern Africa (plus at least one case from Portugal!).

The furuncles are left covered with bacon fat. This encourages the larvae to exit the skin, either due to suffocation or an attraction to bacon. After about 3 hours the bacon fat is carefully removed with forceps at the ready to help fully extricate the larvae

So if any of you were planning a trip to central america, or africa, keep some bacon handy, it might just prevent some uncomfortable furuncles...plus you will be able to eat bacon!

So there you have it, dont say I never taught you anything

-Dr J

Via another doc blog...I have mixed thoughts about this one, but enough thoughts that it is worth you seeing as well

"I am right," said the attending, to a room full of residents at the annual lecture on professionalism and effective patient care.

"See, before you’ve even asked me a question, I’m already telling you I know the answer. Say it with me. I am right. Make it your mantra. You can’t be afraid. All we have is our authority, and as soon as we start letting any doubt creep into our patients’ minds, we’ve lost our power completely. This is what separates us from WebMD. This is what keeps us in business. This is what their insurance companies are paying for. Confidence. Decisiveness. Answers. I am right. I am always right. I am right, I am busy, and I don’t have time for you.

"That last bit is especially important. Patients are expecting more and more from us. 24-hour access. Calls back when they leave a message. An answering service that actually answers. E-mails. Web chats. Doctors on demand. They’re starting to forget how the system has always worked, and who holds all the cards in the doctor-patient relationship.

"Be upfront. 'I don’t have time to hold your hand and walk you through it.' Leave them wanting more. Whether they’re asking about their prognosis, or they’re asking where the bathroom is. You are the one with the information. You are the one with the power. Yield it only when you have to, and tell them only enough to get them to the door. You tell them too much, and they get greedy and want more. And pretty soon you’re spending your whole day explaining the pros and cons of eight different kinds of birth control when really you should just be sterilizing any patient who dares even ask you a question.

"They want second opinions, let them try. But don’t make it easy. 'You can look for other answers, but you’ll only be wasting your time. There are people out there who will tell you anything. There are always going to be people who will prey on your vulnerability and give you the answer you want to hear. They’ll drag you down a path of false hope and wishful thinking, dead ends in the maze of life, until you finally get back to the very same place you’re sitting right now. And we’re just talking about directions to the bathroom, which, as I’ve already said three times, is only for doctors and hospital staff, and we really can’t have you using it.'

"People have forgotten that we’re the ones who went to medical school. Ten years ago, would anyone even think of bringing in a printout of a medical study and asking us to look at it? Not a chance. They would accept whatever disease we’ve told them they have, and learned to deal with the consequences. If your doctor didn’t know something, that piece of information simply didn’t exist for you. We can’t know about every new protocol, every new treatment, every new cure. But the way to learn is not from people handing us pieces of the Internet. It’s from drug reps or the natural course of information-sharing. They can’t expect to have every chance to survive. They’re lucky we give them a fraction of the medicine that’s out there. And we can’t let them forget that.

"Don’t admit mistakes. Blame the patient. Pretend you have to leave. Create a distraction. Hide the ball. Instead of dwelling on the cancer, and how you should have seen it on the previous scan except you never even looked at it before it went into the file, berate the patient for having the nerve to keep you waiting. 'Why people like you don’t go to the bathroom before you come see me will never make any sense. I kept you in the waiting room for an hour and a half. Surely at some point, it could have crossed your mind that you’d be better off going to the bathroom now than waiting until I’m ready to see you. But, no, let’s waste my valuable time—and the less valuable time of everyone else still sitting in the waiting room. I know, it’s too late for this visit, but maybe you’ll remember next time. If there is a next time. The cancer’s inoperable, and I don’t know how much longer you’ll live. So this may be the only time I see you. Thus my last time to teach you this lesson.'

"'Although I’ll try to squeeze in another appointment, since your insurance has an unusually high reimbursement rate.'"

I recently admitted a patient with end stage kidney disease on dialysis who came to the hospital for nausea. When we checked a troponin to make sure he wasnt secretly having a heart attack, we found out that, in fact, he was. Cardiology was urgently consulted, and he was rushed off to the cath lab the same day to have his arteries revascularized and now he is currently awaiting a full coronary artery bypass graft, meaning his heart disease was fairly serious.

In the midst of all this commotion, I did not have time to talk to the wife, but I went back the next morning to answer some of her questions. On my way out she asked what my name was again, she had missed it. I told her I was Dr D****. She said she used to know someone with that name.

My surname is fairly unique so I told her we were probably related, I asked if the person she knew ever lived in New York. She said he used to, but had moved to california a long time ago to work as a teacher, and ultimately with NASA. The last time she saw him was several years ago, shortly before he died of a heart attack.

At which point I realized she was talking about my father.

My patient is employed as a baker, at a bakery in which my father used to apparently visit on a regular enough basis that the name stuck in this womans memory.

Small world, isn't it?