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?

1)A 36 year old drunk gentleman comes in to the ED; the start of any good joke right?

Dr J: any history of cancer in your family

Patient: no, nope, no sirree doc. My parents were both gemini.

2) Or the schizophrenic pt who comes in complaining of back tumors. I look at his back which seems normal enough, if a little, shall we say, fragrant, and dont appreciate anything out of the ordinary. So I start a phyiscal exam, pressing all over as well as auscultating. When I reach the center, he exclaims, yes! there! and there! and a little below, that's one too!

Dr J: sir, that's your spinal cord.

Pt: That's what all the other doctors said too, why doesnt anyone help me!

Of course if the Hospital gets to be too much, I can always go back to clinic...

Dr J: So you said you'd bring in a stool sample this time?

The patient opens up his backpack, pulls out a paper bag, tries to hand it to me. "No, no, we'll give that to the tech-- the specimen cup is in the bag?" He gives me a blank look.

Dr J:The specimen cup is in the bag-- the cup with the sample in it.?

Pt: Oh, you gave me a cup?

Dr J: And you carried this in your backpack?

Pt: Yes

Dr J: Okay, I'm going to get the tech. Next time, just a little bit, in the sample cup. Not the whole thing, not lying in a paper bag. Okay? "okay."

I'm counseling a clinic patient this afternoon about obesity and her high cholesterol, and as we're talking she reaches into her purse...

And pulls out a hot dog. Wrapped in foil, but still... a hot dog. And she unwraps it and starts eating. While we are talking. About her eating habits.
I am literally dumbstruck. This does not happen often. I inform her that she can not have a hot dog in the middle of clinic. Doubly so while I am telling her to lose weight.

"I didn't get a chance to eat lunch."

That is entirely beside the point. you can eat before or after your appointment but not during.

"I didn't get the french fries. I'm trying."

There is a fundamental connection here being missed. I tell her again she will have to put it away, or throw it out.
And then she stuffed the entire thing into her mouth, chewed it up, and swallowed.

"You didn't give me much of a choice."

Ah, clinic.

A Question posed by fellow xangan GreekPhysique in response to his Ask YOU anything post:

"By the very nature of your field (and mine), we end up giving some of the very best years of our lives to hard work for little pay in exchange for a much better deal after 30 (or 40, depends). How do you feel about that trade you have made right now, and how do you keep yourself from thinking you made a bad deal?"

Well Greek, I would start by saying I disagree with your fundamental assertion. From a young age we constantly hear how whatever period we are currently in is "the best years of your life" whether it is elementary school, highschool, college, early 20's, etc. Making the statement that something is the best implies that all the things following simply cannot measure up, whereas I find that each year my life just gets better and better. Not every moment is full of sunshine and lollipops but neither have I noticed a downhill trend as of yet

However, that said, I can appreciate that we do sacrifice a number of potential high earning years until later, while my friends who went into business or law started pulling down six figure incomes before I even was done taking loans or beginning residency. As to how I feel about that trade, I dont regret any of it. I chose to apply myself to medicine with full knowledge of certain aspects of what I was getting into, and I still feel that I would not have been nearly as happy or satisfied in any other field. My other interests, comedy and cooking, I have continued through residency, and when I finally retire from medicine I will pick up and develop those in further detail. So I keep myself from thinking I made a bad deal by continuing to enjoy my life and what I am doing

"Of all the patients in all the clinics in all the world, she had to walk into mine"

During my intern year oh so long ago (over a year! ) I recall seeing an elderly lady who was visiting me for high blood pressure. She mentioned that she wanted to start taking cozaar, a specific anti-hypertensive drug to control her blood pressure. Scrolling through her medications, I saw that she was already on an ACE inhibitor, a similar class of drug and so asked her why she wanted to switch. Was she having side effects? did she feel her bp wasnt controlled?

It turns out all her friends were taking the same drug for their hypertension so she thought she should be on it as well. I explained to her that just because all your friends are doing something is not a good enough reason for me to change your medications. Then, because I was an intern and had to run all my cases by the clinic attending physician, I left the room to go present the case, explaining my absence with a simple "I am going to confer with another doctor and return to let you know the plan." The plan was exactly what I had told her to continue her regular medication but it still had to be presented.

And that was the end of it.

Until about a week ago, when I learned that that patient had gone home and googled me, found out I was a freshly graduated intern (not that I was trying to keep it a secret) and felt that I handled the situation inappropriately, both in my flippant response and my apparent self doubt, as I told her the plan then said I had to check with another doctor for something as simple as a prescription question. She then lost all faith in my diagnostic abilities and decided to go see another physician at a later point to follow up.

How did I learn all this?

The patient is the grandmother of my current girlfriend

Talk about your chance encounters.

Let me tell you a story about 2 patients.

The first patient, a 70 year old gentleman who originally came in to have an electrical irregularity in his heart addressed. While undergoing the procedure, he proceeded to code and was successfully revived, though he required intubation. Several days later, his blood pressure dropped and he required another code. Over the month he has stayed in the hospital, he coded 6 times. Each time he was successfully revived within 15 minutes and in possesion of all his faculties. 6 times he was brought back from the brink of death and 6 times he appeared as though it would only be a few days until the drips could be turned off and the tube taken out of his throat.

The second patient, a 68 year old gentleman arrived earlier this week. Here for a routine heart attack originally, he went into the cath lab and received a stent. Shortly after returning to his room, he also required a code. His picture however was much more grim. One code during which he was successfully brought back, but requiring several pressors, intubation and appearing for all intents and purposes CTD (circling the drain). After the first code, his wife, 10 years his junior, made him Do Not Resuscitate status at the recommendation of the treating physician, who did not expect him to survive another such code.

Yesterday, I was responsible for covering both these patients while the other resident had the day off. The First patient appeared the same as always. motioning with his hands, nodding his head in response to questions no real changes. The second patient also appeared the same. His wife came in to visit and decided his chances of recovery were minimal, and he would not wish to live a prolonged existence in a vegetative state. She requested to change his code status to CMO, or comfort measures only. Meaning begin a morphine drip for pain, and then remove pressure support and mechanical ventilation allowing him to die a natural death.

This morning my fellow resident and I came in to discover the second gentleman sitting up in bed, conscious, and very much alive. When the tube was taken out, he continued breathing. When the pressors were stopped, his blood pressure stabilized. His wife, who last night prepared herself and made the decision to shuffle him off this mortal coil would be arriving to find her husband very much alive. And with no clue that his code status had been changed from full to dnr to cmo in the course of 4 days.

Talk about your awkward situations.

As the second gentleman was making his miraculous recovery, his next door neighbor, the first patient, began coding as he had so many times before. However, this time the man had reached the end of his 9 lives and did not survive the code, passing away on the trip his fellow patient had been expected to make only hours earlier.

Both these gentlemen shared the same last name.

As The Grim Reaper was wandering the halls last night how did he make his final decision? did he flip a coin? was he so determined to collect the one who had cheated him so many times that he left his fellow for another day? or did he accidentally step into the wrong room, confusing one man for another?

Or is a greater force at work?

An 86 year old woman comes to the cardiac unit because she experienced an episode of syncope (e.g. she fainted). An EKG done at the time of her admission showed she was in complete heart block, meaning her atria (the upper heart chambers) and her ventricles (the lower heart chambers) were all beating at complete different rates rather than in one organized cohesive fashion.

Initially, as part of the workup we check her meds, ask her about any history of irregular heart beats and do a ct to rule out a stroke. We also send her down to the cardiac cath lab to examine her coronary vessels for any blockages, MI or embolism being other possible causes of syncope.

And then the surprise.

Her heart vessels were completely clear. No blockages, decent ejection fraction, no apparently obvious reason for her to have suffered an arrythmia and syncopal event.

Until we learned that her husband and son had died one year previously on dec 22nd, the anniversary of which she had celebrated only a few days before her episode and subsequent admission.

Why would that matter? Because of Takotsubo Syndrome aka Stress Induced Cardiomyopathy aka Broken Heart Syndrome

Takotsubo is a sudden temporary weakening of the heart muscle that can often be triggered by severe emotional stress. EKG changes will often appear similar to an anterior heart attack, but on angiogram, vessels will be clear. However, further inspection of the heart anatomy will reveal a bulging apex with a hypercontractile base of the heart

This anatomy makes the heart look like an octopus stuck in a japanese octopus trap or a "tako tsubo". It's though that this is caused by high levels of circulating catecholamines (stress hormones like epinephrine) circulating at the microvesicular level, possibly causing vasospasm.

This condition is somewhat rare, and tends to affect mostly postmenopausal women. In those affected, heart function will actually improve to near normal levels within 2 months provided the individual survives their initial attack. While women are twice as likely to suffer from broken heart syndrome, men are 6 times more likely to die from it.

The good news for my patient is that she survived her attack and got an implanted cardiac defibrillator so if she should suffer another arrythmia she can be knocked out of it.

Bet you didnt know you really COULD die of a broken heart...so next time you see a friend who is down in the dumps, ask them if they need any help with fixing their octopus trap

-Dr J

2 fascinating patient encounters recently:

1)A 40 year old black gentleman, former (only by age) gangbanger and with a friendly but colorful dialect was in the hospital for reasons that are unimportant. However, while taking his social history, I happened to ask him if he had ever had any sexually transmitted infections

"ah shit n*gga, er I mean doc, you mean like that clap on clap off shit? Hell yeah, I had pus all comin out my junk like "blau blau" bu then they got some antibiotics up in this bitch and now it's all good.

I should add that when he said blau blau, he also thrust his pelvis forward as if he was using his genitalia as a sidearm. It was one of the few moments in my professional career where I seriously doubted my ability to keep a straight face.

2) Another gentleman came in with severe burns on his arm. When asked how such a thing might have occured, he related that he had been in the midst of a domestic dispute with his baby mama. She became angry and hit him with the smoove. 

Dr J "What's a smoove?"

Pt "You know, a smoove, that thing you use to smoove out your clothes"

Dr J *facepalm*

After a fairly intense ward service, I have been back on consult for a relaxing few weeks.

Final thoughts on my first month of wards?

*Holy jeebus, I learned a lot in the space of one year-did I really used to know this little?

*It is way easier to do the work yourself than to have to constantly check up on others people's orders; conversely, if you can trust those below you, life is pretty easy

*I cant believe I am the deciding factor in somebody's grades now.

I mean, the med student still has to take the shelf exam, but at least 30% of grades come from evaluations and 100% of evaluations come from me, as I am the only spending any significant time with the med student. Now I understand why sometimes I just got straight B's or satisfactories down the line...I may not have been outstanding or terrible, but you dont want to lie, nor do you want to destroy someone's chances to apply for their field in the future. Apparently I developed a reputation as being a tough resident for constantly "pimping" my student with medical questions. Or at least asking him things to the point where he felt the need to complain to other students I was being hard on him, and they mentioned it to their residents just in normal conversation and those residents mentioned it to me. I figured I was just trying to prepare him for his exam, and never pimped in front of an attending, only gave reading recommendations rather than presentations and tried to teach everyday, but oh well, if thats being hard, then I feel bad for the next student I get.

I got feedback of my own of course as well from my interns in a one on one session who if they were lying to my face, at least told me pleasant lies that I was helpful, low key, and good. And I got a very nice compliment from my attending on the service, who told me I was operating at the level of a 3rd year resident (I am a 2nd year) and he trusted whatever my plan for the patients was and would basically sign off on whatever I did. Given that my last wards service before this was as an intern, and one who failed the rotation due to a particulalry strict attending, this was great validation of all the things I had been second guessing myself on since that time. If one attending can give me straight 3's (out of 9) and a mere few months later another attending with whom I have more responsibilites gives me straight 9's, either i made a miraculous improvement, or I was not as bad that month as I had been led to believe.

The last few weeks have otherwise been pretty eventful, although not in ways I can really come up with an engaging way to tell. Most exciting, I finally got my license in the mail.

That's right, I am now officially a LICENSED PHYSICIAN AND SURGEON. No more calling myself "almost Dr J" even in my head anymore. I shall not be performing any surgeries, but it is nice to know I am licensed to do so.

I have been back on consult service this month, nephrology in particular where most of my patients are on dialysis and I have not been able to think of cool ways to present them on here. Maybe in time.

I also have two grand rounds to present which are basically big hour long presentations to an associated specialty. This week is to the GI department (who I want to join) on applications of probiotics in GI. Next week is to the renal department (my current service) on papillary necrosis. Doing these presentations is a good learning experience and actually not as bad as I was worried it would be although coming up with an academic lecture for an hour is a significant amount of work.

Oh yes, and for those of you following along with my relationship history (or until recent lack thereof) I have broken my gypsy curse and have now been dating the same girl for over a month. She is a PA student who I know from college, and of course there is more to the story, but I will leave that for another time. Suffice to say it is nice to be dating someone who understands my schedule as I am sure my fellow healthcare folks out there can attest to.

So that is the update for the last month. More patient stories to come beginning next week, as I finish up renal and move on to my research elective (aka 2 weeks call of duty time)

-Dr J