*Hello* *hello* *hello* *hello*

Anyone still out there? If you are consider me impressed. I am clearly going through a "meh" writing phase, mostly because I am out doing things. But every now and again it's nice to come back to see how everyone is doing and write myself these little reminders of what it is like going through residency.

So what is it like? I am now a second year resident. I have been keeping this particular iteration of the blog going since my third year of college and for the last 5 years it has been primarily related to my experiences as a burgeoning medical professional. 

As I have mentioned before, being a resident is a LOT better than being an intern. The general hospital staff have a lot more confidence in you, you have a lot more confidence in yourself and it's when you finally start to feel just a little like the doctor everyone you know assumed you were from the day you got your acceptance letter to med school. I make decisions about patient care. Yes I have an attending to oversee and discuss those decisions with, but ultimately, the attending is there as my safety net. I am the one seeing the patient every day, writing orders, calling consultants and in general dictating the plan of care. As an intern I was doing a lot of these things as well, but there was almost the feeling at times that I was mostly there to write notes and follow orders. If I didnt know something, I could ask my senior, or my attending, or just assume someone higher than me would have the answer.

Now, I cant afford to take the luxury of hoping someone else will fix it, when it comes to my patients. In the last year alone, I have diagnosed several people with cancer, others with AIDS, and convinced more families than I care to think about changing their code status. Some of these things would have happened regardless of whether or not I took a leading role. Others only happened because I decided to follow up on something that just didnt feel right. A couple were just dumb luck. But each of those decisions rested solely with me.

It's not something you think about at the hospital. You are too busy with writing notes, or catching up with coworkers at lunch, or attending conferences, or working on research. Every moment, even the idle ones are filled with something. It's not even something you think about that often at home. You are too exhausted and have to do the chores, socialize, make dinner, take care of family if you have them. But every now and again it still hits me how much total strangers place unquestioning faith in my decisions

And those few quiet moments are the reason that you stay past the work hour restrictions, writing notes 2 hours after you finish. why you come in with pneumonia even though everyone in clinic seems to have taken several days off their jobs for a case of the sniffles. why even in your downtime, you end up discussing journal articles or patients. Because no matter how I claim to be more than just my job, it will still be a large part of my past, and what has shaped my ways of thinking and behavior. 

In the end, no matter what specialty you have chosen to go into, the truth is that we are always learning, always thinking, always on call, even if it is only to ourselves for the sake of patients we may not even have met yet. Regardless of when the shift ends, we are all still 24-hour people.

I walk into the patients room, a young to middle aged black female with a pleasant smile on her face

Dr J:"How are you feeling today Mrs X?"

X: "Oh I'm just fine but betty isn't doing too well"

I think to myself what? who is betty? that's not her name. is this a psych patient?

Dr J: "What's wrong with Betty?"

X: "She's just not putting out. She does that from time to time no matter how much I yell at her, and when Betty doesnt put out, I end up in the hospital"

At this point I am thoroughly confused with perhaps the occasional rascist stereotype trying to edge it's way in to my head.

Dr J: I see. well, erm, where is betty right now?

Patient lifts up her shirt and points to her colostomy. "Right here, doc. Where else would she be? That would be weird."

Yes Mrs X that would be weird indeed.

Yes, I have once again added to my body art. The decision process went a lot faster this time. In the past I have taken anywhere from a 6 months to a year to decide on a design, and usually gotten it inked shortly after some milestone... or more specifically each time i passed a licensing exam, step 1 and step 2.

The latest addition:

The overall design is the caduceus, the winged staff of hermes, messenger of the gods. A symbol that is very often associated with the medical profession. So once again, I integrate the greek heritage with the medical, drawing this design together with my other two tattoos. However, doing the caduceus all in cooking implements adds another layer. rather than entwined snakes, a fork and spoon, grape leaves instead of wings and a chef hat and thermometer all serve to show my passion for cooking and food.

So in summary...I am in medicine, and that training will always be part of me, but it is not my entirety. Look closer and you see my heritage, my hobbies, my interest in the arts. While my other tattoos remind me of where I came from, and where I want to be, this one is me in the now. It's how I see myself, three in one, all coexisting.

 
My first tattoo, the amida buddha (compassion) and it's story

My second tattoo zeus and the evil eye (faith) and its origin

So I have three very permanent reminders of food, faith, compassion...my very own eat pray love

Despite my earlier post and your natural assumptions, I have continued to work a little to refine my personal statement everyday. It's still a train of thought but at last a cohesive idea is beginning to take shape. Your thoughts and comments, directions on where to go, what is not going to work, etc as always, are appreciated.

---

GI is a specialty of contrasts. Where some of the greatest technological advances are being made every year in fields like capsule endoscopy, virtual colonoscopy, endoscopic ultrasound...for the technophile, it is pure heaven. At the same time, travel abroad, to rural villages and you find the physical diagnosis skills are still just as important, with the GI physical exam revealing just as much information as ever. The digital rectal exam is still the best way to detect prostate cancer. Jaundice, asterixis and hemangiomas will tell you about a cirrhotic patient long before you can reach a ct machine. Ascites doesnt require anything more than a glance and a touch to diagnose and another simple low tech procedure to treat, although even that has been given the higer tech accompanient of ultrasound. The joining of the old and the new seen in GI is perhaps the best field for the physican of my generation...learning to balance the classical diagnostic skills of the time honored tradition and those who came before while making use of the knowledge from those far ahead.

The majority of the health problems outside the united states are often gastrointestinal or infectious in origin, and quite frequently both. The knolwedge of how to diagnose and treat gi bleeds, hepatitis, and a host of other intestinal anomalies,gives me an incredible set of tools with which to travel. And ultimately, I would like to do so. I am a hands on kind of guy, I want to travel to rural areas with doctors without borders, combine my love of being abroad, with my love of medicine.

I spent a month in china learning acupuncture and traditional chinese medicine and the number of herbs they use is astonishing and an excellent area for further research. Already spices like turmeric and ginger are making strides in treating conditions like inflammatory bowel disease, nash, and being used as promotility agents. This only further helps to tie in another of my hobbies with GI, cooking. I could become a better chef and researcher at the same time.

Liver patients also pose an interest to me...they are among the most complex patients any doctor has to deal with and the constant fine tuning of those with chronic conditions, up to and including transplant hepatology is just as exciting. finding the right recipe to keep each person thriving, with no two patients the same.

So why do I want to do GI? A long tradition as a specialty, mixing old techniques with new technology, the opportunity to perform procedures and intervene directly with the patient from pegs to colonoscopies all the way up to transplant. A chance to deal with acute issues like bleeds or pancreatitis to chronic follow up patients like ibd or cirrhotics. Skills that can help me in the old and new worlds, and ones that already tie into my hobbies of traveling and cooking. Advances in research being made into long overlooked traditional remedies alongside new pharmaceuticals that offer promise where before there was only maintenance. What first appears to be a field of contrasts for a man of contrasts, ends up coming full circle to being a unified specialty for a man with a single goal

--

yes yes, i know i need more things about my personal statement and less a glowing paean to the gods of GI, but before I can write anything to make this personal, I had to figure out all over again why i wanted to do this, and hopefull I am getting closer to that.

In honor of this here talk like a pirate day, I thought I be telling you landlubbers a story about me latest scalliwag of a patient. Naught but 3 moons ago, I be having a man come visit me for scurvy. He also be mentioning that he wanted to quit smoking before it be sending him to davy jones locker. So I wrote him a shipoard pass for nicotine patches. He set out to sea and was told to follow up on his next leave. Earlier this week he be returning to me galley for a follow up. I asked him how his smoking be. 

Pt: "Arrr, doc, i be thinking these nicotine patches you be giving me no have worked. I still be smoking and now me left eye be infected"

DrJ: "Listen ye salty sea dog you- wait, what? Why would your eye be infected unless...?"

That's right me mates and lasses. This gentleman, like a true pirate, had been wearing his nictoine patch OVER HIS EYE for three months. And nobody had said anything about it to him. 

While the accents may have been changed for today, the above story be totally true. Enjoy the rest of your talk like a pirate day!

Yo ho, yo ho, a pirate's life for me!

We pillage, we plunder, we rifle, and loot,
Drink up, me hearties, yo ho.
We kidnap and ravage and don't give a hoot,
Drink up me hearties, yo ho.

Yo ho, yo ho, a pirate's life for me!

We extort, we pilfer, we filch, and we sack,
Drink up, me hearties, yo ho.
Maraud and embezzle, and even hijack,
Drink up, me hearties, yo ho.

Yo ho, yo ho, a pirate's life for me!

We kindle and char, inflame and ignite,
Drink up, me hearties, yo ho.
We burn up the city, we're really a fright,
Drink up, me hearties, yo ho.

We're rascals, scoundrels, villains, and knaves,
Drink up, me hearties, yo ho.
We're devils and black sheep, really bad eggs,
Drink up, me hearties, yo ho.

Yo ho, yo ho, a pirate's life for me!

We're beggars and blighters, ne'er-do-well cads,
Drink up, me hearties, yo ho.
Aye, but we're loved by our mommies and dads,
Drink up, me hearties, yo ho

Yo ho, yo ho, a pirate's life for me!

Aaargh! Happy Talk Like a Pirate day, mateys!

Please enjoy these medical themed comics while I have no patient stories to tell.

This is a typical day at clinic.

I had an epiphany today. A moment where I realized just how far I have come in the last year.

The day was full of little moments like that. I stayed one step ahead of the attending on my patients-I had ordered chest x rays and abg's on my ventilator patients, getting them ready to be extubated or monitored and the like. I spoke with the radiologists to secure a test for a patient that we had been told previously our hospital didnt do, and I found the secret way to do it. I convinced yet another family to make their loved one DNR/CMO and allow them to pass with dignity (I am getting far too good at that one unfortunately)

But the one that struck home is when, working on my notes in a quiet room, I heard a sniffle behind me and turned to catch one of the interns crying. Two weeks into residency, one of her patients was deteriorating, on a fast road to nowhere, and neither she nor anyone else on the team could figure out why. The family was aware of the poor prognosis, but the patient was still full code, meaning everything would be done if she were to stop breathing, things like cpr, defibrillation, intubation and a number of other things that may temporarily prolong the patients life, but not preserve its quality. 

The Intern had to go and discuss code status with the family given the impending prognosis of the patient. Two weeks into being a doctor, this poor girl was faced with trying to convince a family to avoid invasive procedures, to let their family member go if something should happen, to convince one group of people to allow a loved one to die naturally...nor could she even offer them a reasonable explanation as to why the patient was dying. 

I could understand why she was overwhelmed. It was less than a year ago that I had been in her shoes (hell, two weeks ago I still WAS an intern) and had no clue how to even pronounce a patient, much less convince a family to change a code status. I sat down with her, and reminded her that it was okay for us not to know what is going on with a patient, that often despite our best efforts people die, that as scary as it is for us, the family is often more scared and looking to the white coat as a symbol of authority for help and guidance. I told her to use the shield the coat provides, to give her recommendations with confidence whether or not she felt it, and above all, to SIT DOWN while having this discussion.  

She thanked me, and I went back finishing up my notes for the day. On the drive home I realized, I had finally become a resident. It wasnt about my breadth or depth of medical knowledge. It wasnt about having endless compassion or brisk efficiency. It's about knowing the right thing to say at the right time where it will do the most good, whether it is for your patients or your peers.

Well played, Life, Well played.

-Dr J

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Intern year has come to a close. But is the completion of the first year the end of the beginning, or the beginning of the end?

Before, when I had a question or a concern about my plan of treatment, or a finding, or anything at all, I could always ask my senior if I couldnt find the answer on my own. There was no concern about stupid questions, because as an intern, I was not expected to know much about the finer points of medicine, only the basics. Now, I am the senior, and the onus of knowledge is on me. While I can still review my plans with an Attending, the expectation is now that I have already exhausted any resources before bringing up a question.

No longer do I have a team to rely on, a fellow co-intern to suffer with on tough rotations. Second year is mainly spent rotating through subspecialty services, where it is just myself, a fellow and an attending. I will see my fellow cointerns nee coresidents in the cafeteria and at clinic, but now if we dont make the effort to see each other and socialize, opportunities are no longer quite as available. It will be interesting to see how friendships developed over the first year play out over the second.

When I am on an r-service, it will be my responsibility to help teach the interns, to catch their mistakes and help them when things fall through the cracks. To arrive earlier, and stay later because I AM the safety net I used to have. What kind of resident will I be? Will interns want to work with me, or will the hospital rumor mill make a rotation with me something to suffer through?

This is also the year I start applying for a fellowship, a medical subspecialty. Setting off once again through the carnival of research, recommendations and rigamarole that applying for anything carries with it. I have to finish up the paperwork to obtain my medical license so that I can start writing prescriptions for my increased panel of patients.

Its a lot more responsibility, a lot more risk, and hopefully a lot more reward. A lot has changed in just one night, even if I dont particularly feel like I have.

Here's to hoping i'm up to it.

-Dr J

And Now, more medical webcomics

For the last 4-5 days, I have had an unstable patient I have been working my ass off to keep alive. 15 different problems, the top three of which were acute respiratory failure requiring mechanical ventilation, shock believed to be septic (infectious) in origin requiring pressors, and acute renal failure on the short road to dialysis. In short, this guy came in with multi-organ failure. 

And the very first day he came in, he also was having atrial fibrillation and a minor heart attack, meaning I was rushing around trying to put in a central line to give him the pressors, checking blood gases and labs every hours giving this person ridiculous amounts of my attention. And from that first day he looked like he improved a little. Still seriously gravely sick, but not at death's door. At best, in death's driveway.

I got in touch with his family, and found out he was DNR (do not resucitate) on day 1. Yesterday, on my day off, the covering doctor called the sister and gave her the daily update about his steadily failing kidneys and inability to get off the respirator, telling her basically she might want to consider coming in as his condition was looking worse by the day.

She responded that she couldnt as she lived out of state, and told us in accordance with his wishes to withdraw care, initiate comfort measures only and let him die with dignity. She made only one request.

"Before you extubate him, could you please give him a hug so he doesnt die alone?"

...

I could use a hug myself.