Homage to the guilty pleasure Overheard in New York :

• Drunk Crotchety Man, slurred speech: You want to take these off of me! These restraints are doing more harm than good! You want to take these off me immediately, and by immediately, I mean 20 minutes ago, if not sooner!
• Nurse: Do you have a favorite spot for blood draws?
  Cute Elderly Woman: Yes, but it isn’t on me!
• Snarky Nurse: What were you drinkin’ tonight?
  Waaay Drunk Man That The Whole ER Knows By Name, slurred speech: Vodka!
  SN: Oh yeah, what kind?
  WDMTTWERKBN: Stolgate!
  SN: Oh yeah, never heard of that kind.
  WDMTTWERKBN: It’s 2 dollars!
  SN, laughing: Oh yeah? That must be why. I’m surprised, I had you pegged as a Grey Goose kinda guy.
• Me: So what brings you to the ER tonight?
  Elderly Gentleman With Glasses Reading Investment Book: Pissin’ blood!
• Me: Do you do any drugs?
  Same Elderly Gentleman With Glasses Reading Investment Book: Heroin, Speed, Meth, hell, I’m high on speed right now!

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Great lines from Panda:

No Atheists in the Call Room

Despite having scoffed at religion for your whole life, disdained the faith of your parents, and professed to only believe what can be experienced by the senses, on your first night of call you will find yourself praying the universal prayer of the new intern, “Please, God, don’t let anything happen tonight.”

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I’ve been watching Grey’s Anatomy to relax in my few hours of freedom per day, and I must say, nurses totally get the shaft on the show. Addison is always rooming patients in the ER, checking vitals, and hanging fluids, as if the physicians on the show are these solo practitioners who can do everything for everyone (surgical interns staffing a free clinic, ha!)

ER nurses can laugh with the best of them, and are incredibly fun to work with when the patients are stable. They’re even more amazing to watch when patients go bad. One patient went from looking mildly uncomfortable to coding (needing CPR) in the span of about 3 or 4 minutes, and just like a switch was flipped on, the nurses swooped in and knew exactly what to do. Two secured IVs, another started documenting, and a fourth was pulling meds. I’ve seen the phenomenon a number of times now, and it’s really, really impressive. The teamwork is fantastic. One of the reasons I love the ER.

I remember a patient once asking a Peds nurse why he went into nursing. His reply: “I wanted to help patients. Doctors diagnose patients, but it’s the nurses that actually treat them.”

My hat is off!

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Back in 2nd year of med school, I thought learning about tertiary syphilis was rather silly. I figured people would definitely get treated once they had a chancre or any signs of secondary syphilis . (Speaking about US-only right now.) Turns out patients don’t read the textbooks, and don’t live in my little imaginary medical bubble world. Life always comes back and bites you on the ass.

About two months ago, I open up a chart and see: “Patient here for lab results positive for neurosyphilis .”

Graham’s law: The disease you don’t study, or decide that you’ll read about tomorrow is the disease a patient will come in with today. It’s happened to me so many times I’ve lost count. Always makes me read that one extra chapter, ’cause I figure I’ll get burned if I don’t.

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4 hour “orientation” shift today.

Already learned how to put someone in restraints and tie them down, saw a patient from the county jail, and re-did an IV on an altered patient who had already ripped it out twice. I was also told to “fight for a suture room and grab it before someone else does.” Grabbed my patient, maneuvered her bed around the drunk man who had urinated in his bed and the onto the floor.

This month is going to be awesome. And crazy.

Possible theme for the month, advice given to me by an attending today: “Better to ask for forgiveness than permission.” (Did I mention I can write my own orders?)

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Knee slapper from the NYT :

President Bush told Congressional leaders Thursday that he would veto any legislation that weakened federal policies or laws on abortion.

In a two-page letter sent to the House speaker, Nancy Pelosi, and the Senate majority leader, Harry Reid, Mr. Bush said his veto threat would apply to any measures that “allow taxpayer dollars to be used for the destruction of human life.”

(That’d be my emphasis.) I guess President Bush doesn’t count the $585 billion for the Department of Defense , much of which goes toward guns, bombs, and missiles–pretty sure those have destroyed thousands of human lives in the past few years.

Irony!

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Another year, another reason not to get sick in July. That’s right, it’s the guide to clerkships/rotations/clinics/whatever you wanna call it. (If you’re not there yet, you should be reading Graham’s Guide to Boards .) Probably not worth reading if you’re not a med student.

Let’s begin at the beginning.

1. Get used to feeling stupid. I often forget this fact, but when I remind myself that I’m supposed to feel this way, it’s much less damaging to the ego. Every first week of a new clerkship, you will feel like the biggest dumbass in the world. You will make boneheaded mistakes, be totally overwhelmed and confused, and will often feel very alone, like you are the only person that has experienced this. It is not the case. In the pre-clinical classroom, you learn by memorizing. In the clinical classroom, you learn by experiencing (or at least, I sure do). And you learn much better and faster. I think part of the reason you pick up things so quickly is that there is so much to learn on each rotation that your brain doesn’t have any other choice. Back to my original point–it is okay to feel this way, so don’t let it get to you. You have residents who do this thing night and day, and attendings who’ve done this thing for 30 years, who argue about minutae for fun. You’re not going to be at their level any time soon, don’t sweat it! (Note: most of this is internalized stupidity or ignorance–in no way do I think anyone else should be belittling you or making you feel shitty. I had a jerk surgeon who humiliated me in front of the entire team my very first week, presenting my very first patient ever to an attending, but I felt much better when the entire team told me his behavior was uncalled for.)
2. “You gotta do your job.” I stole this quote from my surgery chief resident. Don’t half-ass your way through clerkships, do at least what is expected of you. If you don’t, you’re just making even more work for your already-overworked team.
3. Be enthusiastic. This goes ridiculously far, especially in your first 6 months of clinics. You may not know anything, but showing interest and trying counts for a lot.
4. Do. Not. Lie. Your attending or resident will ask you a question about a patient–because either you forgot to mention it in your presentation, or they’re curious, or they want to make sure you didn’t miss something, or I guess sometimes to pimp you–and you will be tempted to think “If I just say that there were no carotid bruits, then at least they won’t think I’m stupid for not checking them”–but just don’t. “There is nothing I hate more than liars,” quoth my Surgery clerkship director. “I can teach people that forget things, but I can’t ever trust liars.” Just be honest! Say “I forgot to check that, but I’ll make sure to right after we’re done” and jot it down. Or if you can’t remember what the patient said or what you found on exam, just say so. You’ll gain trust and credibility, because they are expecting you to miss stuff. You’re just beginning your training!
5. Be professional. What does that mean? Professionals put others’ interests (usually patients’) above their own. That means being on time–always–being appropriately dressed, being respectful of colleagues and patients. Figure out the team’s level of fun/sarcasm/joking/crudeness and don’t go past it, I’d say.
6. Ask questions. If you’re confused, or are lost, or need help, ask. It’s not a sign of weakness, it’s a sign that you’re thinking through things on your own. That being said, there is a time and a place for asking questions. “Which one is the superior mesenteric artery” is probably not best asked when your attending is screaming for suction ’cause he’s just hit said vessel.
7. Be aggressive, and ask for responsibility once you think you’re ready. Maybe I’m just a gunner here, but the clerkships I’ve enjoyed the most have been the ones where I’ve actually felt like I’ve contributed to the team. The worst ones have been me shadowing fellows or writing H&Ps that the intern or resident is going to basically write again him or herself. You’re paying a pile of money to work, you might as well get something from it and “help people” finally–isn’t that what you put on your med school application?
8. Clarify stuff up-front. If you don’t know if your attending likes long thorough presentations (medicine) or short’n’sweet ones (surgery), ask. You won’t waste their time, and you’ll need to learn how to present both types, anyway. (Presentation types to master: the one-liner, the consultation request, the 3-minute, and the 10-minute.)
9. It doesn’t matter what you take first. I know surgery residents who took surgery first and matched just fine, just as well as surgery residents who took surgery toward the end of their first year. It will not kill you. The earlier clerkships will expect you to have more pre-clinical knowledge, while the later ones will expect you to have more clinical knowledge. It all balances out.
10. Certainly not least: MAKE TIME FOR YOURSELF! While it’s great to go above and beyond, don’t stress yourself or drive yourself crazy. Clerkships are rough because you’re expected to learn clinical medicine, manage patients, and still be studying once you get home on both your patients’ conditions and the clerkships’ classic diseases, too. Do your best to find a balance. Make time for your significant other, if you’re lucky to still have one by this point (cynical much, Graham?), try to get together with friends once every week or two, go out, live. Appreciate the time you have outside of the hospital–clerkships really make you do this.

The transition to clerkships can be rough, and at times, very lonely. You go from spending every moment with your classmates as a preclinical student to being thrown around different rotations at different hospitals with different schedules. You often lose your support network, because they’re all busy, too. Lean on non-medical friends if you have them. They’ll enjoy hearing your gross stories about doing rectal exams and weird diseases you’ve seen, and you’ll get a chance to catch up with them.

Oh, and I found a nice physical exam review site tonight if you’re interested. Those skills tend to weaken while you’re studying all night and day for Boards.

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I’m pretty sure one of the best parts of graduating from medical school (or, at least, being in your final year) is never having to file Financial Aid paperwork.

FAFSA isn’t actually all that bad–it’s mainly just typing in numbers from your tax return, but the “College Scholarship Service” application is ridiculous. “How much change do you currently have in your pocket?” I’m not that far off.

One of the most annoying things is the fact that I have to bother my parents with this crap. Although I have been financial independent (translation: racking up debt) since 2002 when I graduated from college, to the Financial Aid department I am not officially “independent” until I’m 30. It’s red tape crap so they can give me several thousand dollars more of loans, since there’s an expected “parental contribution” that I have to borrow money for to pay off.

Last time ever for this crap!

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I had the pleasure of talking with Atul Gawande last night at a mutual friend’s house while he was in town to do a book reading for Better , his new book. (Coincidentally he has an Op-Ed on the Walter Reed situation today in the NYT.) Although I haven’t read it yet, he read some excerpts, and they were fantastic.

I was kind of nervous to talk to him at first–he’s quite an amazing figure, being a surgeon and excellent writer (not to mention he’s a freaking MacArthur Genius ). We got into an interesting discussion after I had asked him about his articles and their influence on people–I, for example, was sure he wrote his Geriatrics piece in the New Yorker to raise awareness about our unpreparedness for the aging population. He pretty much said I was wrong: everything he writes he writes because he wants to understand it, and writing is his way of thinking his way through things. He doesn’t write to make change, more because he has found an interesting paradox that he wants to understand. He said he doesn’t want his writing to “do bad,” and if it does good, it’s a bonus–but that in general he didn’t think that people reading an article is really the way that change happens, anyway. (He said, however, he believes that his Center for Surgery and Public Health , however, does have a role in implementing change–he would like to develop a “Surgical Apgar” score to finally get basic reporting data from surgeons so they can measure themselves and learn how to improve.)

It was at first disheartening to hear that this Genius grant Harvard cancer surgeon award winning book author who gets asked by the New York Times to write Op-Eds doesn’t write to change or improve things–especially when so much of his work is focused on why we fail, and how we improve. But I guess I can somewhat understand his claim. It’s much more fun (and less frustrating) to think through a problem and try to figure out why it’s happening than it is to propose a way to fix it. He said one of his goals in writing is to show that “the world is more complex than most people think it to be,” and maybe that’s in part why proposing solutions is so difficult. And maybe it’s easier to keep writing with a simpler goal in mind–understanding the problem–than fixing it. If you advocate for a fix all the time, and nothing ever happens, I can see it becoming frustrating.

Sometimes I wonder if my efforts in educating/advocating for health care reform would be better spent in another venue besides my little home, home on the web–or similarly to Atul–just educating people about a problem, without proposing a certain solution. I guess for me, however, it always feels like I’m just complaining if I don’t propose some way to fix the problem at hand. But then again, I’m no Atul Gawande, who has a way of discussing problems with such curiosity that he can get away with it much easier than I can.

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