Medicine and ICU

Phew, it's been exhausting!  I had a month on internal medicine service where basically every day for 12-15 hours I'd be at the hospital managing a panel of patients and admitting new ones from the emergency department.  It was rough, and there was plenty of weekend hours put in as well.  I had an easier time of it compared to some of my colleagues because, again, I'm pretty comfortable with electronic medical records and working with computers in general.  I didn't have any real time to do readings, however, so now that I'm on ICU which is more about learning than having any intense responsibility for patients, I'm finally able to catch up on all the stuff I wanted to review.

For example, while on medicine service I saw at least 3 cases of "acute pancreatitis," with two legit cases and one (maybe more) case of not-so-legit pancreatitis.  I finally had time to go to the American Gastroenterological Association website and find their guidelines for acute pancreatitis and read up on the latest "word" from the experts.  We definitely weren't managing the patients ideally, we were managing them fine but not particularly ideally.  That's one of the challenges in medicine is that it's a constantly evolving field and you have to stay super up to date on the latest treatment protocols and what the studies are saying.  We even have a website that is essentially a wikipedia for physicians, called "UpToDate" - the name says it all, it's where doctors go to stay up to date on information.  However, UpToDate isn't always the best organized website and I don't particularly like how it's structured, plus the articles aren't necessarily peer reviewed by experts in the field based on only the best, most solid, studies.  That's where specialty society guidelines come into the picture.

In ICU, we actually had a pretty 'exciting' semi-TV moment of emergency patient care - an older woman currently on a ventilator suddenly started having blood come up her nasogastric tube, so essentially she suddenly developed bleeding and her vital signs showed she was in distress.  The rooms in ICU should be bigger than they are, and this one felt particularly cramped.  The crash-cart was between the end of the bed and the opposite wall, and I was on the inside half of the room and my attending (a very intelligent younger doctor who looks more like a college student than a seasoned ICU doctor) literally ran over the bed to get to my side so we could insert a chest tube - he didn't have a gown on (just a white coat with the sleeves rolled up to his elbows) and ended up getting sprayed with some of the fluid when the tube was in - he had eye guards in place at least (aka glasses).  Then we immediately pulled from the other cart a fiber optic cable to see where the bleeding was coming from and it was essentially seeping from every surface in her lungs - diffuse alveolar hemorrhage as they call it.  No source to suture, cauterize, or slap a bandage on - just have to keep giving her suction, oxygen, and start steroids.  She had developed a chronic lung condition over the past year and it was not going well.

Heroics aside, ICU can be a very difficult place.  We had a young girl come in and die within hours, and it shook the ICU physicians and staff for the next several days, and it made news in the community.  It's not part of the plan for young, otherwise healthy people to suddenly die of overwhelming bacterial sepsis, but it happens and there's very little you can do to stop it.  Also, one of my patients who I had been managing a week prior on the normal hospital floors for a pneumonia and fluid in her lungs, a very sweet older woman with mild Alzheimer's dementia, ended up choking on her morning breakfast and ended up in the ICU on a ventilator, likely with brain damage from lack of oxygen.  She had been on a dysphagia diet, but hadn't been officially evaluated for her swallow by a speech therapist - her eating challenge wasn't obviously apparent, it was more that she would eat too fast and choke slightly on her food rather than any physical deficit.  I hadn't seen her since, and she was probably going to be discharged from the hospital that day or the next to a rehab facility and then an assisted living home.  I don't know if it would have made a difference to have that swallow evaluation or not, part of me thinks it would have gotten her out of the hospital, home, and then maybe a little longer in this world, but on the other hand, it may have only been a matter of time before something like that happened.  If she'd been switched to a liquid only diet, would it have changed anything, or would she have developed an aspiration pneumonia later and ended up in ICU in a month anyway?  She died that night - no code was called, so it's likely the neurologic findings were dismal and the family agreed to withdraw life support.

On the more positive side of things, I've been appreciating more how much patients like seeing their doctor in the hospital, even if it's a resident physician.  It's still hard for me to see myself as a REAL doctor, but we are making decisions for the patients and know them better than the attendings.  We check on them two or more times a day, not including all the calls to the nurses, reading up on previous visit notes, calling their physicians and specialists, and checking and ordering labs and radiographs, which patients don't get to see.  After I moved to ICU service, I went back and checked on one of my other patients from medicine a few times, as she was an especially complicated case, and helped the new team manage her discharge a bit.  She was really appreciative that I was still coming and managing her - she had had a somewhat 'flat' affect and wasn't all that talkative or cheerful so I wasn't sure initially if she even liked seeing me, but she made it clear later that she was glad I was still involved in her care.  Another patient I had discharged a couple weeks ago, a young person who had gotten frustrated several times while in the hospital about being kept there for treatment and had landed himself there by some fault of his own, came back today to get some paperwork filled out and actually said of the doctors who were coming to see him he liked me the most and was glad to see me.  I was his regular doctor, and when people are in pain and are grumpy it's hard to tell if they're mad at you or if they think you should be doing something that you're not doing.  I'm glad to know that even the patients that I think are not satisfied with their care do actually appreciate the work we do.

In another example of networking and working as a team, I talked to a nurse who had semi-challenged me on a medication decision.  Long story short, I thanked her for voicing her concerns, because after the fact I went and re-examined the data behind the study that a senior resident had very emphatically told me was going to be the new standard of care, and decided that the risks do not outweigh the benefits.  Initially she may have thought I was blowing her off because I told her my justifications for wanting to prescribe the medicine which, don't worry folks, never ended up getting taken by the patient because he felt like refusing meds and even if he had gotten that one dose before I discontinued it, it's the kind of medication that takes time to build up to a therapeutic level.  I didn't HAVE to talk to her about it, as it wasn't really an issue, but I elected to for a number of reasons.

First, it's important for nurses to feel respected and not marginalized in a very hierarchical system where doctors are traditionally seen as their opponents, not partners.  We rely on them for patient care and we want them on our side and voicing concerns, when legitimate.

Second, nurses talk - if she thought I had blown off her concerns, she probably would have gone complaining to all the other nurses that I'm a bad doctor and endangering a patient, or that I'm one of "those doctors who think they are better than nurses," and I have to work here for the next three years.

Third, if nurses think their patients are in danger and that physicians aren't listening to their concerns, they will start doing things on their own - which in rare cases does help patients, and in many other cases doesn't, like times when nurses think a doctor has prescribed too high an insulin dose, pretend or abstain from giving it to the patient, and in the morning the patient has blood glucose > 300.

Fourth, good karma.

Well, at the end of this week, I'm free for two weeks to do whatever - my first vacation of intern year.  When I get back I get to jump into OB/GYN... Not looking forward to it very much.  On the plus side, I got my call schedule for next month and I won't have to do a weekend shift for the first two weekends, which is great since on the first weekend there is a Cardiovascular Symposium I'd really like to attend!  I've got a bunch of nice stuff planned for my vacation, and can't wait to get started, but I'm also really liking the pace and learning opportunities in ICU.  Having an attending who likes discussing the latest care guidelines and is passionate about evidence-based medicine is always very invigorating - it's the most academic we get, as clinicians.  Time to go read more stuff!

A Couple Weeks In...

Well, still at it - doing the whole doctor thing.  It's fun, though I still gotta say I like clinic the most.  Clinic is where I see myself practicing most of the time.  Right now, though, I've got another week of Emergency left.  It's fun, it's interesting - a fair few procedures and such.  Only thing about it though is it's all very short term - essentially putting a bandage on someone's problem.  I would find that very demoralizing after a while.  I guess it has the same appeal as surgery - there's a problem, and you fix what you see in front of you.  Maybe it was my education at an osteopathic school, but I just don't see the appeal.  Or at least it doesn't really feel like being a 'doctor.'  You don't even get to do elaborate labs when you have an interesting case - it's just 'not our problem, they'll work that up later.'  The lifestyle is somewhat appealing, a few long shifts then a few days off, but still - doesn't have the same appeal in terms of feeling fulfilled.  

Right now trying to figure out what I should focus on learning on my own - there's so much stuff to learn more about, and it's hard to know what to focus on.  

Also enjoying being employed - getting paychecks is great.  Once I get used to the schedule of how things work I'll feel better about everything and a little less stressed - scheduling in enough sleep is the biggest challenge.  I want to get more out of my day when I've been gone a long time, and end up cutting into sleep.  Almost August...my how time flies.  Well, I think I'll try to read up on one medical topic and one medication each day.  Or every other day.  Whichever I can accomplish.  I'd really like to at least know what receptors everything acts upon - some of them I know but some I just memorized what you use them for.  The nuances count the most...

As far as my crusade against poor management of mental health in outpatient medicine, I'm still not backing down.  Still using my PHQ-9s, documenting them, discussing it with patients... it would be really hard to manage some patients if I were limited by time the way the real doctors are.  I'm given a lot of time to see patients and hear their stories, and I'm really thankful for that.  It'll be a challenge in the future when I have to boil down a 45 minute psychiatric visit into a 15-20 minute visit that includes their other problems.  Gotta pick the battles where you can...

First Week of Residency Year 1

Well, I've had about a week of being a resident - I have to say, parking in "Doctor's Only" spots, getting all the free cafeteria food I want, introducing myself as a Doctor so-and-so, it's been pretty great!  It's taking a little getting used to, but it's fun!  I'm finally having a part in patient care and I think the confidence that comes from having decent decision making skills is making me better with my patient interactions.  Also, I have electronic medical records down almost like a second language after only a day or two.  I haven't used this system before, but I've always been good with computers so...after two years of gritting my teeth while watching my attendings attempt to chart patient visits, finally I am the one doing that!  

I've started out with clinic and homeless medicine - which is very interesting and it's a pretty easy way to start out.  The hours aren't that long and I get to do a lot of reading and videos.  I like that I get noon conferences - kind of a daily lecture on random stuff.  Also the commute from my place is less than 15 minutes no matter where I have to go so far!  For emergency, which I start next week, it gets a little more tricky - I might end up driving 30 minutes each way.  My first call is this weekend, luckily it's 7pm to 7am, starting on Saturday, so I get to sleep in and get both days to hang out and do stuff.  

Pretty much all moved in up here - our place is all settled, wedding and honeymoon are all done for now, time to get back to work...  I'm trying to start out with good habits - always taking care of things on time, staying organized, you know.  The things everyone says they'll do but usually don't do.  Well, I'm hoping to do them!  Anyhow, time to enjoy my evening... after a long day running around trying to keep a bunch of things straight in my head...

As a PS:  I keep seeing emails from recent medical graduates, international, caribbean and domestic, all sending us their applications hoping we've had a vacancy or to get started for the next round of residency applications.  All I can say is I am sooooo thankful to be done with that and finally I can stay put for three years and get paid money!  MONEY!  It's not much but it's something!  

Next Steps...

The last day of fourth year/rotations was last Friday - my last two rotations were allergy/immunology and forensic pathology.  It was quite neat seeing how they track bullets through people and the various gross findings in freshly deceased persons.  At any rate, I'm finally done and I am looking forward to putting Touro behind me and moving onto better things, with my excessively high 300k debt following behind me.  We have our apartments in Davis and Redding secured, and soon I'll have to do some PALS training, computer training, ACLS, BLS, etc.  That won't be until June 19 though, so until then I get to relax and do some prep work for those things, and the wedding.  The wedding is the last hurdle - I'm half excited and half wishing it would just be over already, since we've been planning it for months and the Bora Bora honeymoon awaits us...  

Wish I had more to say.  I'm sure some of my experiences on the rotations are worth reporting but all I can think about is wanting to get away from Touro and start earning money.  I'm tired of just racking up debt in an overpriced institution (when you look at the national averages...) and standing in rooms while doctors and patients interact.  I'm tired of waiting and watching and want to start DOING.  Yes, it comes with responsibility, stress, and long hours, but I want to start moving forward in my life.  This is a big year in terms of moving forward, and I want to get on with it!  Graduation is June 2, tomorrow I'm picking up my regalia.  Soon...  soon...

Match Day: Redding

Well, the results are in and my match is Redding - specifically the new Shasta Community Health Center program for Family Medicine up in Redding, which shares its first year training curriculum with the Redding Family Medicine program.  Basically I am looking at 3 years of training and I should get a well-rounded family medicine education, considering the community-based nature of the program and the resources available.  

What this means is that now my fiance and I must change our current living arrangement - while we had really hoped to stay in the Sacramento area, in many ways Redding may be a better fit for me.  It emphasizes clinical medicine more than one of the Sacramento programs, UC Davis definitely wasn't a real "fit" for me, and the other Sacramento program would have been a close tie with Redding.  However, the fact that the Shasta program wants me makes them all the more desirable.  Currently we are looking for two bedroom/two bath cat-friendly places in Redding, and tomorrow will investigate a one bedroom/one bath place in Davis.  Hopefully schedules will work out so we can spend maximum amount of time with each other.  The other two residents in my program so far (they are still interviewing for a second PGY-2 spot) are both married with children, as are most of the previous years' Redding residents, which hopefully will foster a supportive environment for married individuals.  

I am starting to get excited about checking out the Redding area - see what the local area has in store for us. Our current landlord let us out of our lease agreement, since we signed without knowing we would be moving.  Didn't even charge us for backing out of the lease, which I definitely appreciated.  Hopefully we can sign a lease tomorrow and get that element squared away.  Heading to Monterey for a bit then going to start an Allergy/Immunology rotation.  

Interviews: Done

Well, all is complete.  Finished all my interviews, am one week into vacation, and it has been a busy vacation indeed!  After getting my thank you notes all figured out, had a weekend in Monterey to take care of wedding vendor business (Florist, Cake, and Hair/Makeup).  We also have a guest for the month, and another guest coming next week.  It's nice to be busy with only fun things.  Ordered the Save-the-Dates, got the guest list finalized... just riding out the end of the month.  Things are pretty much going awesome, and I feel very confident that I will match at my top choice, and if not then my second choice, both in Sacramento.  I doubt Davis will rank me particularly high, and after that one then Redding and Modesto are perfectly feasible options.  

Not too sure what else to update - I feel very fortunate compared to some of my classmates.  I know what I want, I'm competitive in the field that I want, I'm compatible with the field I want...  Compared to others who don't know what they want or aren't competitive for what they think they want.  I'll probably hold off on any more updates to this blog until I start my Neurology rotation in January, and then the Emergency Department rotation mid-January.

Change in Reception...

Well, this was certainly a little different than the previous places I went to. Today's interview day went okay. It was mostly negative, though. First off, none of the residents who were showing us around seemed to know what they were doing. The day started off with a tour, instead of an orientation like all my previous days had started, so we didn't even have an agenda. The person giving the tour was an intern resident, who has only been with the program since July and hasn't even worked in all the hospital departments yet. Usually it's a 2nd or 3rd year resident who does the tours. They also were frank about telling us some of the negatives about the program. When we got back, first I was with a faculty member and she seemed to start off a little colder but she warmed up gradually. Went over my application, I got a bit of a skeptical vibe from her, but I kinda shrugged it off, it didn't seem to be a big deal. After that interview, I was with a current resident who was pretty nice and seemed to like me fine. He even told me a little about the criteria for ranking people, which he probably shouldn't have, and said that being a Spanish speaker, interested in OB/GYN, underserved and rural medicine, etc. are all part of their checklist for whether to rank someone or not. 

After that came the program director (PD). I was willing to give him the benefit of the doubt at first, but he didn't seem particularly warm or excited about me. Certainly not like the Sutter had. Sutter probably knew I had genuine interest in them based on me doing the sub-internship, and I had spent a month with them being nothing but nice and pleasant and enthusiastic. I basically felt like the PD here started the interview with the assumption that I was a lying game-player trying to dupe them into thinking I wanted to be in their program so they would rank me highly. For one, he didn't seem enthusiastic or happy at all when I said (TRUE) stuff that matched their mission goals. I DO want to work with Spanish speaking patients, I DO want to have full-spectrum experience and know what resources are available to uninsured patients in California. I don't want to do nothing but OB/GYN but I'd like to be able to handle my primary patients when they get pregnant instead of sending them off to a "specialist".  He basically told me not to rank them unless I really wanted the program, and whenever I said what I liked about the program he seemed entirely nonplussed and just reiterated his previous statements. He even went so far as to say that it's "better to scramble for a residency than match at a place that is just a backup." 

Also, mid-interview, he asked about my Spanish experience and then proceeded to say (in MEXICAN Spanish) "How about we chat in Spanish for a bit?" At first I was thrown off because he used the Mexican-Spanish word for chat instead of the more common verbs like hablar or charlar. I never use the word he used, but based on the context of the rest of the sentence I figured it out after a second of confusion. I asked what he would like to discuss and he said tell me about a patient I saw in the past year. So I start telling him about a patient, and I wanted go on, since I was starting to get going better, and he basically cut me off and played it off like he just likes hearing peoples' accents. First off, part of me feels like he intentionally used the Mexican parlance to make it more challenging. Second, he didn't even let me talk long enough to hear much of an accent, OR let me get in the rhythm of it. He knows it's not my native language, and interviews are somewhat stressful even when you're a competitive semi-confident applicant. Obviously he was checking to make sure I didn't just lie all over my application.  I was expecting to run into someone who would want to speak Spanish with me as a subtle 'test', after all, they always say never to overestimate your language skills unless you can conduct the interview in Spanish.  It wasn't the fact that he tested me, but his skeptical expression and tone. I kind of wonder if it was because my personal statement seemed overly-tailored for their program - I only tailored the very last short paragraph, but the rest of the personal statement (the generic family medicine part) just so happens to perfectly suit their mission statement over the other programs a bit. My scores are also pretty competitive.  Maybe on paper it looks a little too good to be true for their program.

Either way, I had been starting to consider that the place might be nice to be at, if it came to it - it would definitely give me my Spanish experience, the residents all seemed pretty chill and nice, and the earlier faculty member I was interviewed by seemed nice and interesting.  Plus its location is pretty nice is near some nice places.  Ultimately, this program director's attitude was a complete turnoff, and the PD plays a pretty significant role in your residency training over the next three years.  I don't want to have to be around someone like him who treats me in such a judgmental manner and isn't even open to hear what I have to say. One of the other faculty members also attacked a 3rd year student from UCSF who was giving a talk about a global non-profit organization she started before medical school that was reducing maternal morbidity and mortality worldwide.  After we finished clapping and it was opened up for comments and questions, the first guy who raised his hand was this faculty member who essentially told her that some of their efforts were a waste of resources and time, and that they were going about it wrong.  Not a single word of encouragement.  A couple other people commended her after that initial commenter, and of course she took the initial criticisms in stride, but...I was upset because her accomplishments were honestly quite impressive.