One week remaining until I submit my fellowship application. You may remember I was undergoing a crisis of the faith for a while as to whether or not pursue fellowship at all. I then completed a month of elective in GI and Hepatology which thankfully reaffirmed my desire that even though I detest research, it is something I am willing to suffer through for the greater ultimate goal.

On Nov 15 the ERAS website opens for submission of applications. I will be applying to approximately 10-15 programs located in souther california, chicago, miami, and a few scattered other locations. I have obtained my letters of recommendation from my program director, a gastroenterologist, and a hepatologist. I have almost completed my personal statement, meaning the one thing lacking from my application is research.

But guess what!

I finally published! The research project I have been working on since intern year was recently accepted and will be appearing in an upcoming issue of Clinical Gastroenterology. The project itself deals with treatment of hepatitis C in liver transplant patients, and most of the projects I am involved in relate in one way or another to treatment of chronic liver diseases.

So, my application can now be presented in full with proof of a dedication to scholarly pursuits and the all powerful publication to put on my CV.

In one week, I can submit my application.

And then we wait.

*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 have been MIA for quite a while. Chalk that up to finishing almost 3 months straight of ICU care, with the last two weeks being night float. As a second year resident, every one of my non-ward service calls is as the overnight doc in charge for the ICU.

36 patients, every one of them in critical/intensive conditions, plus whoever is hanging out in the ER, and any issue that comes up, be it for renewal of restraints to sudden desaturation requiring intubation and a breathing machine is dealth with first by me. Later by the fellow, if I call and cant handle it. But the buck initially stops with Dr J. 

For added fun, I now get to run codes. That means when someone's heart stops beating, or they stop breathing and a code blue is called, the one doc expected to head up the team and tell everyone what to do, and for how long. Now of course everyone knows their job and it's not like I have never been at a code before...it's just a little intimidating to realize that the big decisions are now in my hands.

On the plus side after a month of ICU, a month of Pulmonary consult (most doctors who run hospital ICUs are pulmonary/critical care specialists) and two weeks straight of nights being on call for the ICU, I feel pretty comfortable handling almost any kind of critically ill patient. I also got some of the hardest months out of the way early on, so I will be well prepared by the time I go to wards service.

In the meantime, I am kicking back with a little bit of research/hospitalist elective for the next two weeks while I continue to decide about applying for fellowship this year. Start my gastroenterology (GI/digestive system) elective later this month, and should have some more stories to share at that point.

In the meantime, I guess I can take a step back and say I have continued to grow as a physician. So hey, good for me!

-Dr J

I Am in the midst of a real mental dilemma here.

For the last several years I have expressed to various parties and in multiple forums my interest in gastroenterology as a subspecialty in internal medicine. I find that dealing with the complications of liver failure, inflammatory bowel disease and similar digestive complaints to be among the medical cases I am most fascinated in. I love the procedural aspect of GI, endoscopies and colonoscopies feeling like some hi-tech medical video game. I love that GI is one of the nicer lifestyle specialties in internal medicine, and if I were to succeed in it, I would financially be pretty much set for life following the completion of my fellowship.

However, GI is among the most competitive subspecialties, right up there with cardiology, and critical care. Similar to my applications to medical school and then residency, there are always more people than positions available.

A Key component of Fellowship is academic medicine, i.e. research. The emphasis is on projects that explore new hypotheses although case reports and meta-analyses/reviews of existing studies is also encouraged and accepted.

And therein lies the rub.

I detest research. I have absolutely no interest in it whatsover whether it be benchwork, clinical studies, chart review, etc. The sum entirety of my interest in and love for medicine is all clinical. I like seeing patients, going to clinic, rounding in the hospital and basically making a 9-5 living (although realistically medicine is never a 9 to 5, I think you get the gist). Once I leave the hospital, I honestly stop thinking about everything that is going on in it. I have other interests. I enjoy cooking, performing stand up comedy, riding motorcycles, a whole slew of non medically related activites.

Yet in order to successfully secure a fellowship position, I must have something published by the time I apply, or at the very least be involved in several projects I can talk about during my interviews. 

I have told myself in the past that my love for the field is strong enough to put up with just enough research to get me the fellowship position, that once I make it, I can just have a clinical practice and its worth the sacrifice. I got myself involved in several projects beginning my intern year doing things like chart review and data entry on cirrhosis patients, who academically I find fascinating.

But I am beginning to wonder if I cant keep lying to myself like this. I really dont like even the minimal amount of research work I have forced myself to get involved in. And if by some lucky stroke of fortune I manage to secure a fellowship position anywhere in the country, the emphasis is going to be, at the very least, another 3 years of constant research and publishing before I can find a job just doing clinical work and never have to worry about publishing anything ever again. And I am beginning to realize I have serious doubts about my ability to stay motivated through that path.

The alternative option would be for me to become a hospitalist, an internal medicine doctor who deals strictly with patients in the hospital managing a multitude of problems from every organ system. Sure I would take a paycut in the long run (avg income for hospitalist is 150-180 thousand versus 200-250 thousand for a gastroenterologist) but I would also be able to start working soon as I finish residency in another 2 years without an additional 5 years of training, without the need to ever do research and pretty much avoiding academic medicine entirely.

I have things I want to do with my life still-I want to open my own restaurant, I want to continue traveling the world, I want to not still be some form of student when I am approaching my 40's. I can accomplish these goals no matter what choice I make, only the timetable and perhaps a few lifestyle choices are affected.

Of course, the majority of my friends and colleagues have heard me talk about GI from day one. Now while there is no shame and only minimal loss of face in changing my mind at this point, I of course have to wonder, would I be changing my mind for the right reasons.

Everyone has aspects of their job they dont like-am I overdramatizing this one feature and cheating myself out of a career I could really love? Or am I saving myself from 4 years of jumping through hoops when I could be just as happy doing none of the circus tricks required to do the kind of medicine I want to do? And if I do decide not to apply, what then do I tell to the colleagus and coworkers I have just spent the last year convincing I want to be in the field?

Any other resident/fellow/subspecialists out there, I could really use your thoughts on this if you have been in a similar situation

And the remainder of my xanga readers, what is your input?

The whole thing has left me with mental knots in my stomach 

I recently reached another significant marker in my career as a physician. I received my first gift from a patient.

I have been following this lady with fibromyalgia since my first day as an intern. She is one of the few patients I see who I actually have any continuity with. And the reason for that is because like many fibromyalgia patients, she comes into the doctors office for an appointment approximately once a month for varying complaints. The kicker is that she has a fear of doctors, needles, and anything medically related in general, making her condition that much more onerous.

Every visit would turn into a friendly argument. She would have a complaint, I would recommend tests, she wouldnt get them, I would lecture her about smoking, she would tell me politely to stuff it and so on and so forth. This particular visit started no differently, but about halfway through she took out a card and box and handed it to me.

I hadn't saved her life. I hadnt cured her of any disease. I hadn't done any tests that led to a one in a million discovery and diagnosis. All I had done was lecture her every month for the last year on smoking, and provided the occasional prescription refill.

The card was a simple thanks for understanding my fear and feelings, and attached to the gift was a tag addressed to Dr J from "A stubborn patient," a humorous understatement at best. The gift was a small glass and gold bear with a stethoscope which now sits on my desk.

I was touched. Several of my other doctor friends had told me during their intern year of receiving cards, cookies, gifts, etc from their patients and admittedly I was a little jealous at the time, wondering if either my patients were unappreciative of the efforts I expend to cure, treat, or sometimes just put up with them (hey, pobody's nerfect) or if I was just an unlikeable or interchangeable doctor. And to receive a gift from a patient who I not only had not made an extra effort to be friendly to, but instead has treated slightly paternalistic as I saw her repeatedly for similar complaints...

...well, I guess I should stop trying to guess what people want from me, and just do what I think best. It seems to be working out pretty well thus far.

-Dr J

On several occasions I have written about making a patient DNR (do not resuscitate); about the difficulty, the responsibility, the power of convincing someone to just let their loved one go, to not force them past their allotted time on earth. I have written about how I have helped others deal with this all too common modern medical situation. I have written about why I think it's a good idea that everyone have an advance directive. 

And yet, I realized I have never written about how I actually go about it myself. You know my basic formula based off Dr Folkmans advice, but how does one go about convincing a patient or family to change from "do everything humanly possible to keep my loved one alive" to "I dont want them to suffer anymore, if anything happens let them go."

Well the first thing I always do is introduce myself. Nobody wants to be having life and death discussions with a stranger. So my goal from the get go is to build trust and rapport, to convince the family I am on their side, that I am using my education and experience to do what is best for everyone. Next I ask what the family understands of their loved one's condition thus far. Oftentime people may be unaware of just how sick their loved ones are. They see someone come in with a minor infection or some mild chest pain, and not understanding the disease process, become frustrated or surprised when people appear to get worse in the hospital, a place they brought them too for healing. When the family explains how much they know, it gives me a better idea of how much further I have to take them.

I repeat myself. Often. I use a lot of stock phrases such as "his condition is very serious" or "she hasnt been doing well" peppered liberally throughout my talk. If anything I sometimes use my authority to overestimate slightly how close a person may be to death, so the family has no choice but to confront the issue now rather than a last minute phone call in the middle of a code by a covering doctor or someone from the crash team.

And after I have explained what is going on, after I have told them what critical interventions we have been doing to simply maintain the current level of awareness/health however dubious it may be, I start rolling out the big guns, and just like on Jeopardy I do so in the form of a question.

"Now have you and the patient ever discussed what treatments they would like if they were in this condition?" 

Unfortunately, in many people the answer is no. So I take two steps forward and one step back. I try first to personalize the issue for them, reminding the family that they know the patient better than I do, and ask them about their quality of life before hospitalization compared to know with whatever hospital needs they may require. I ask them if the person was standing there with them able to see themselves lying in a hospital bed, what would they want done. Would they want to continue in this way.

This may all sound very manipulative, and I cant deny that on some levels it certainly is. But I am not just running willy-nilly through the hospital trying to off people left and right. The people I take this approach with often have been unable to confront this on their own, have been in a state of denial and even if they decide they still want everything done, futile care though it may be, even the discussion gets them started with the process of preparedness, of acceptance, of realistic expectations.

That said, I dont leave people all open ended with a simple here are your options, full code, dnr, or cmo. That would be failing both myself and them. Most people are rarely confronted with the complexities of death on a daily basis and may not know when treatment is futile. For a doctor to tell them all this and then walk away saying what would you like is as useless as not discussing the subject at all. After the discussion noted above, I offer my recommendations. I tell them, if it were my family member, I would make them DNR, or cmo if the case warrants it.

And then I emphasize that do not resuscitate does not mean do not treat. Just because I dont think someone should undergo the suffering of rib fractures from compression, or electrical burns from defibrillation, should not be subjected to weeks on end of mechanical assisted breathing, should not lie in a bed full of tubes pouring out of every orifice does not mean I instantly leap to withdrawing care and starting the morphine drip. I start back at square one reminding the family how serious the condition of their loved one is, and ask them to consider allowing a natural death, or a death with dignity to occur if the body simply cant take anymore rather than forcing them back into life repeatedly.

I carefully avoid any reference to my own religious beliefs unless directly questioned. They have no place in this discussion, although respect for the families beliefs does. I repeat these conversational tidbits until the family gives me a clear reasoned response. Either they agree with my recommendations and change the order, or they tell me they still want everything done. And regardless of my own feelings, I accept that clear answer when given. If I disagree, I wait until another day and bring the issue up again. Sometimes it takes a few days for the veil to lift from someones eyes.

After having just one of these discussions this morning, one of the fellows relayed back to me that the nurses had spoken with him and told him I had done a great job of handling the family and discussing one of the harder topics in medicine. While nice to hear that I am deemed by my peers to be performing so well, I wish I hadnt become so proficient at this talk so quickly.

-Dr J

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

Related Posts:

Last Words

How to Break Bad News

I have been neglecting those of you who still come here, I know. I also know that this meta-regretting is a typical way for me to start posts lately. So by way of brief apology, let me just say I do miss those of you who i have virtual conversations with, and I will make more of an effort to at least comment, if not post more on my own.

That said, I finally began service on the wards today! Yes, my 2 months of night float are over, and now I am back to a more classical residency block...admitting patients, rounding on them, and treating them until they get better, get transferred, or get dead. Ideally less of the latter.

Now I am a fairly proactive person, so when the resident was handing out patient assignments I volunteered for the liver patient. Liver patients tend to be complicated, as since the liver metabolizes most drugs and produced the majority of clotting factors and proteins, pts with defunct livers have a ridiculous amount of things they cannot be prescribed or have to be monitored closely to prevent multitudinous complications.

One of these complications is known as Ascites. It is basically a fluid buildup in the abdomen due to loss of proteins by the liver. But while i could get technical all day, lets consult Dr Google for a picture, shall we?

The main way to treat an ascites that has gotten this bad is to drain it. That's right, just stick a needle in and deflate the belly by draining all the liquid into vacumn sealed liter bottles. Did I mention the yellowish ascitic fluid can occasionally be reminiscent of beer

That's right, my first day on wards and i was setting up my own microbrewery!

So cheers to my first completed procedure of the year! Anyone want a stella?

An orca fat patient (BMI 40) came in for diabetes and sleep apnea. As part of the social history, she mentioned she loves disney, especially the little mermaid. During which the following song would not leave my head (to the tune of part of your world)

Look at my fat
Isn't it neat?
Wouldn't you think my belly's complete?
And wouldn't you think I'm the blob, the blob who ate...
Everything?

Look at my rolls, how many's untold?
How much jelly can one belly hold?
Lookin' around here you'd think
Sure
She's eaten, everything

*(yes, inner me is horribly insensitive. often outer me too in non professional settings: deal with it)
-------------------------------

Then 18 year old male patient who could, perhaps, be a bit more worldly
Dr J: Have you had any unusual discharge from the penis, or any burning when you urinate?
Pt: "I have a white discharge, but only when I'm excited."

------------

and from one of my nursing friends...

Gentleman comes into ER with 3y/o child w/ c/o fever. i go into the room to do a rectal temp. father pulls down the pull-up and i go to it. the child screams "no, not in the butt!!" the father replies " yeah, you and your mother both" ...