Vacation Ending

It is my last day of vacation. Bummer. I have had a nice 6 days here getting some vitamin D, looking at pretty scenery, and generally chilling. We went snorkeling with sea turtles yesterday. Totally awesome. Today, I saw sea turtles at the aquarium. They looked a lot healthier in a way. I guess a life free of predators and full of regular feedings leads to a shinier shell without barnacles and other various perks.

I have noticed it takes me longer to unwind during vacations the further I get into this medical training adventure. The further you go, the more stress and responsibility builds up. While I have always preferred to take trips to cities or to do things outdoors on vacation, I am starting to see the appeal of the do-nothing vacation just for this reason.

There is an interesting Atul Gawande article on the Senate Health Care bill. Check it out.

Okay, off to the beach one last time. Tomorrow I will be spending on the airplane, so I'd better get some fresh air while I can.

Vacation

Ahh... vacation. The joy of doing nothing except eating, sleeping, relaxing, and taking in all of the tropical beauty around me. Hawaii rocks, and I highly recommend a trip if you have never been. Over the past few days I have hiked through a rain forest to magnificent waterfalls, done a lot of swimming, eaten tons of coconut shave ice and guava juice, and generally chilled at the beach. It sure beats work. Pictures to come upon my return to the mainland.

Happy Thanksgiving!

Happy Thanksgiving everyone! The Lone Coyote is finally emerging from a 2 month block of brutal scheduling, where she barely had time to eat and pee, much less blog. She is very thankful that no elective surgeries are done over the Thanksgiving weekend and she is not on call, so she now has 4 days off to rest up.

On that note, let me mention one thing I am very thankful for. Pathology Assistants. If any of you out there are applying to pathology residencies, one thing you should try to get a sense of is how much grossing you will be doing in residency. You need a program where the volume is high enough that you will see interesting things, but not where it is so high that you will be grossing all of the time. Grossing can have very little educational value if you are just cutting in small ditzels and cassetting biopsies for hours. We are a very high volume program and have PA support. They do a lot of the small stuff and free us up to focus on learning how to do the bigs. This makes our grossing days sometimes heavy, but doable.

This past week I had a grossing day without PA help due to vacations and it was a nightmare. We are talking over 14 hours of cutting, much of it being of little learning value. Then you ge tto go and try to take care of all of your other work. By the end of a day like that you are just cooked and resentful. I have talked to people who routinely have days like this in their residencies. I cannot imagine doing that day-in and day-out and surviving, much less learning much of value. So be careful. Find a place where you do not just work long and hard on grossing days doing volume, but you do good cases. There is no glory in being a cutting scut monkey.

Okay, off to enjoy the holiday. I will try to be better about posting now that things should improve schedule-wise.

Time Flies

It is hard to believe it is the middle of November already! Such is life, I suppose, when working really long days with tons of cases to deal with. I am more than halfway through a 2-month block of surgicals right now at our main hospital. This is definitely the roughest section of my schedule this year and it is wearing me down. On one hand I am "in the groove" in terms of rolling with the schedule and getting my cases done. On the other hand, it is a long stretch to work at such high intensity and the burnout starts to set in after about the 5th week.

When I think about how many patients cases I have seen, it is pretty mind-blowing. Sometimes clinicians call and ask, "do you have results on Mrs. Smith's biopsy?" They seem shocked when I have no idea who Mrs. Smith is. If she has a rare presentation or an awful diagnosis I can often remember who it is once they tell me some history. But if Mrs. Smith had a standard GI biopsy that showed nothing, I have to look it up with the medical record number. It is just a different way of caring for patients. The resident on the other end may have a handful of patients that they know well. I have stacks of "patients" that I know 1-2 sentences of history for and am constantly trying to turn over cases.

I am looking forward to December when I get some elective/vacation. The temptation after all of this is to do very little on elective, but at the same time we are expected to use the time to fill in gaps in our education. It will be nice to do some work at a more relaxing pace though.

On Street Sweeping and Other Musings

It was a light-ish day on frozen sections so I had some time to ponder a few random things. An update on my last post about ENT surgery: we have had more eyeballs arrive, so it seems that enucleation is done at least somewhat frequently here by them. There is an Eye Pathology department that some of the eyes seem to go to. But it is unclear to me when they go and when they do not. Hence the reason why we sometimes get to cut them up. Yuck.

I was driving in the other morning and there was so much traffic approaching the hospital. It was just bizarre. Looking ahead I realized that the street sweepers were out since it was within the designated street cleaning time. And driving all around me were huge vehicles--SUVs and trucks. After a few minutes of inching slowly along the street, I suddenly realized that all of the SUVs and trucks were circling the block and waiting for the street sweeper to move on. Then they were swooping in to claim the few spots that were large enough for their huge vehicles. It seemed pretty cut-throat. I have always wondered how people can deal with owning large vehicles in the city and parking them on the street. Now I see it can be quite the sport a couple of mornings a week.

My best frozen section of the day involved being called down to the OR long before the specimen was ready. As I stood there waiting, I watched chaos unfolding around me. It seemed this surgeon was driving the nurses crazy by making constant demands. They were running in circles trying to meet all of the surgeon's requests, which held up the frozen even longer because I could not get the specimen and leave. Finally, the surgeon realized I was still standing there and demanded to know, "what are you still doing here?" "I'm waiting for the specimen."

Now he got pissed. He started yelling at at the circulating nurse, "why is she still waiting? What are you doing? Go and get the specimen and give it to her. I need this analyzed and time is being wasted." One of the scrub nurses chewed him out a bit, "maybe if you stopped asking him to get you so many things, he could get the specimen ready!" I was happy to get the specimen and get out of there as the fireworks started,

Then we get the frozen done quickly, diagnose cancer, and I run down to the OR with the results. The freaking case is done and the patient is in the recovery room already! Yeah, that frozen was really so important for the outcome of the case. How fitting.

The Mystery of Otolaryngology

The unbelievable has happened this week. I have been home before about 9 or 10 pm in the evening! With all of this free time I hardly know what to do with myself. Perhaps that is why I began to ponder otolaryngology.

Ah, ENT, a specialty that medical students strive to match in. But after being exposed time and again to the specialty in the OR and the gross room, I really have to wonder why is this field so popular? The high income aside, of course. Maybe someone out there in the blogosphere can enlighten me on this?

Here is the way I see it. The surgeries that we get specimens on are long, brutally long, lasting the whole day or even into the night. They seem to involve digging around in very small spaces in the face with random names that I tried to block out of my brain soon after that unit in first-year anatomy. Even worse, these spaces are often filled with puss, fungus, tumor, necrotic debris, or other goodies.

They dig and dig to pull out a tiny little piece of tissue and then call us for a frozen section. Um, okay, we'll see what we can do with this limited sample. Granted it is being pulled out of someone's maxillary sinus so it's not like any more tissue can be obtained. Sigh... but it can make things difficult.

Then the next day the specimen arrive on my bench in 19 tiny parts which all have to be measured, inked, and dictated. If they need decalcification it slows everything down for another day.

Wait, this was supposed to be about ENT, not my work, so I digress. But let's talk about enucleation for a minute. I hate these specimens. Not a lot grosses me out at this point, but seeing an eye staring up at me out of a container really freaks me out. The eye had a long suture attached to one end. When I called the ENT surgeon (very nice guy) to ask about orientation, he told me, "oh that was just for us to pull on."

Whoa... pulling eyes out of the socket. Another reason, or not, to do ENT.

Garbage In, Garbage Out

Sometimes when I go down to get specimens from the ORs for frozen sections, I feel like there is a huge disconnect between us and the surgeons regarding how we do our job. I guess it must seem that we appear, pick up the piece of tissue, disappear for awhile, and come back later with the results. It's magic: tissue in, diagnosis out.

Let me tell you, it is not quite that easy. And to make the magic work there are a few things that can help the spell along. Unfortunately, we sometimes do not have much help in this regard. Here are just a few examples.

1. Adequate specimens. Okay, you gave me a huge container with a piece of Telfa in it that I race back up to the gross toom. Is there anything here? Maybe if I hold the Telfa up to the light... oh, wait, there is a tiny fragment of soft tissue that is maybe 0.2 cm? On a good day? Hmmm... now you are angry because because we need to "defer to permanent" to really call what it is? Let's think about this for a minute...

2. Bovie-licious. In the same vein... I return to the gross room with another container and open it. What is that smell? Is that a new BBQ dish in the cafeteria? Or the smell of the fast food from across the street? Wait... that is wafting off of the specimen. Singed flesh smell. The specimen is charred, black ball. Guess what we see under the scope? Bovie artifact! And maybe not much else.

3. Clinical history. Believe it or not, we do play a role in the patient's care. Yes, the patient's care. We're not just looking at tissue in a vacuum. It helps to have some clue of why we are even looking. That box on the specimen requisition sheet about clinical history? Just one legible sentence with the patient's presumed diagnosis or presentation and the surgery they are undergoing can be a big help. Oh, and when I ask for history in the OR, speaking clearly and not being rude is really helpful too.

4. Orientation. I am not a mind reader. And, unfortunately, I was not there when you pulled that tissue margin out of Mrs. Jones' pelvis. So there is really no way for me to know which side of the specimen is anterior. Putting in a suture to orient the specimen and telling us what it is can go a long way. Oh, and about those sutures, please just keep it simple. If I see a rainbow of different lengths of various suture material sticking out of the tissue from every possible angle, it's just a hot mess.

You Know You Are A Pathology Resident...

... when you are cooking chicken stir-fry and realize that the pieces of chicken you just cut and are stirring about are all frightfully symmetrical.

The Thing?

The Thing? Exit 322.

What the hell is it? That was the question we pondered as we saw billboard after billboard along I-10 in the southern Arizona desert advertising "The Thing." In case you could not guess, this type of gimmick that promises total randomness in the middle of the desert is what The Lone Coyote lives for. There was no question about it. Once we hit Exit 322, we were stopping.

We hit Texas Canyon, home to some very wild and other worldly rock formations. The rest area was closed, unfortunately, so I did not get to take any cool pictures there. Shortly after exiting the canyon, we saw it the magical exit. The Thing?! What is it??



Uh, it looks like a gas station in the middle of the desert with a big gift shop and an attached Dairy Queen. Inside we found the typical tacky desert souvenirs--animal carvings, jewelery, "rattlesnake eggs," cheesy T-shirts, and Mexican jumping beans. At the back was a huge metal door to nowhere with a $1 admission fee. It took some convincing to get the Mrs. to agree to enter, but I prevailed.

The lady took our money and told us to follow the yellow footprints through the other buildings. Other buildings? These yellow tracks were supposed to be made by Bigfoot, I guess. There was no turning back. We went through the heavy door and entered the first of several open-doored bunkers. That was about the time we realized we had forgotten the camera. It was in the car. After some consideration we concluded there was no way to exit, get the camera, and re-enter. So, sorry, no pictures from here either.

The buildings were full of completely random, and kind of creepy, stuff. There were the "one of a kind" wooden sculptures of people being tortured, a collection of ancient guns including one from the Ottoman Empire (supposedly), and some strange creatures that appeared to be made from tree roots. Then there were the collections of "artifacts," which included old cars, including one that was supposedly Hitler's, a buggy that Abe Lincoln once rode in, and random old household items. Then there was the more "ethnic" stuff--an ancient Chinese stool, Native American baskets, and random pottery.

In the last building one can find out what The Thing? actually is. I will not spoil it, in case you are ever driving along I-10 and want to find out. You can Google it if you are really curious. Let me say you'd likely never guess what The Thing? really is. The whole experience was totally awesome in its randomness, even if it was a bit creepy. I love America.

Well Blog

There's some good discussion/cathartic rambling going on at the NYT Well Blog. If you are a frequent reader of the Well Blog, you may be familiar with the links to Dr. Pauline Chen's columns and the responses. In a nutshell, she is an academic surgeon and will often write something about a current issue in medicine, particularly regarding medical education/training. She usually starts with an anecdote from her own training/teaching experiences, then finds a recent study that addresses the main point of said anecdote, and ends by interviewing the author of the study who offers his/her ideas about how we might change the system. Often, she addresses topics that are "taboo" to discuss in the hospital, like this week's topic: when physicians, especially stressed out residents, have "distress" in their lives, it impacts the care they provide to patients.

Now my first response, as it often is to these columns, is, "did we really need to conduct a study to reach this conclusion that seems so obvious?" But since the culture of medicine is not to address issues related to stress/being overworked/ balance in life/etc, I guess unfortunately the answer is yes. What I enjoy most about the Well Blog referencing her columns are the comments that soon appear. Several players dominate the discussion:
1. MDs - usually we hear from current residents/young physicians about the hell of residency currently, older generation MDs whining about how easy our generation has it or about how much medicine now sucks, a few voices from somewhere in between acknowledging the horror of training and the need for change, but reminding the young ones to remember why we entered this profession in the first place.
2. MD Haters - a few people will then start posting that MDs need to stop whining because our salaries are too high, we all have god complexes, we knew what we were getting into, we drive up health care costs, etc.
3. MD defenders - some people, often nurses, jump the aid of MDs and talk about the high debts we have when finishing, the awful hours in residency, the declining reimbursements, and the difficulty of seeing so many patients in limited time.
4. Lawyers/PhDs - then some other professionals, usually JDs/PhDs start posting about what they go through, how they work 80+ hour weeks/slave in labs and have debts/low wages, are underappreciated professionals too.
5. Some MDs then start to post again whining how the attorneys need to get off this blog because "we save lives" and being a lawyer is never that stressful. They then say the PhDs should go because they do not have the debts we do.
6. Repeat, around and around.

Will the problems ever get solved on the Well Blog? Probably not. But I do think the discussions are good because they give the public some idea of what goes on behind the scenes in health care. And they provide MDs/other health professionals with a virtually anonymous way to voice their feelings, which they often cannot do elsewhere. It can be a lot of negativity, but there has to be a place to let that out if it is not safe to do elsewhere. I think that is one reason why sites like SDN and medical school/resident blogs get traffic. Communal sharing of the pain is one way to deal with it.

Here were a few choice comments from anonymous MDs (not me, thankfully) on the current Well Blog discussion on the residency experience:

I’m currently in my internship and I would love for the next generation to be able to survive their training more healthily than I am.

1. Doctors from before the 80 hour work-week LOVE to hassle this generation for being weak because we don’t have to work more than 80 hours a week or 24 hours in a row. BUT:

It is just not HUMAN to work 24 hours in a row.

For anybody.
I don’t care if you are scooping ice-cream or folding socks, 24 hours is not do-able, the human mind can’t stay sharp, being awake for 24 hours does bad things to your muscles, your digestive tract, your mind, your circulation. As doctors shouldn’t We know this? For gods sake people, I come off a 12 hour shift with leg edema! After 24 hours I want to scream at people even when they are just being people and I’m pretty mild-mannered!

One of the arguments against changing shifts completely every 12 hours, for example, is that there are many details lost in translation between shifts. The ability to communicate succinctly, easily, comfortably are not skills that are valued in the application process to medical school. These skills are in fact underdeveloped in most applicants because we are still pushing those who are ‘good at science’ into this role of physician and unfortunately studying science can be a solitary and unsocial effort. Medical schools and residencies market themselves as looking for well-rounded individuals but they rarely consider anyone with poor scores or grades.

2. Psychology and therapy are not bad words. Why shouldn’t it be mandatory for anyone taking on the job of caring for others to spend time examining themselves, their motives, their influences. Cognitive Behavioral Therapy for example can help with depression, anxiety, perfectionism. If there is ever a group of people I have seen who ALL suffer from these and need some therapy it is medical students.

3. Hospitals are unfortunately extremely unhealthy places. The food for both the staff and the patients is generally low-quality. There is no respect for the act of eating and taking breaks. The only breaks universally accepted are smoking breaks. Wearing scrubs while it is comfortable, I believe, contributes to the normalization of obesity among the staff.
It smells bad. The lighting is depressing. The facilities in community hospitals where much of my training has taken place are deplorable. Why not have intelligent and sensitive and HUMANE architects design the next generations hospitals? With a little aromatherapy, more break areas and areas designed for quiet reflection (who hasn’t hid in the clean utility room to cry when things get overwhelming) hospitals can be less hostile toward those working there and therefore also the patients.

4. The bullying. The elephant in the room in the hospital is the overwhelmingly negative behavior between staff members. It is considered wimpish (and maybe un-American?) to complain about bullying as an adult, but there is an attitude of pouring the negativity that is poured on you onto those below you in the hierarchy. This happens within residency programs, between nurses and doctors, toward the medical students, the aids, the social workers, it is everywhere. How can people who supposedly want to help people treat each other with so much hostility? I think this daily. The culture of negativity and complaining and talking behind people’s backs and criticism without encouragement, etc, etc, creates such a malignant environment that any doctors with a shred of sanity and humanity left opt out leaving behind those who create and harbor the caustic attitudes.

5. I could go on and on but I have another 24 hour shift tomorrow…

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

Residency turned me from an upbeat, happy, optimistic person into a crabby, ultrasensitive, irritable, depressed and angry person. There are the “80″ hour (my record was 107 hours) work weeks, the “24″ hour shifts (my record was 37 hours straight - without sleep) up to 3 days a week, the condescending and power-hungry attendings who belittle residents and tell them “how easy they have it nowadays”, the average 12-14 hour work-days full of nonstop beeping beepers/paperwork/inability to scarf down a snack or even go to the bathroom without 23 interruptions/and legitimately sick patients, the four days off a month (to pay bills, buy groceries, change the oil, call your parents, and “do all that reading” so you don’t feel like a complete idiot when you’re being pimped at 6 AM the next day in front of 10 other people), the friends who leave you because they “don’t understand why you never call them”, the sheer constant exhaustion that never goes away…

…and you do that for 3-6 years of residency! Of course you get depressed and distressed and hate yourself and the world and that damn patient who comes in in the middle of the night requiring emergency surgery. Of course you very seriously consider dropping out of residency… or life altogether, as a woman in my class attempted to do.

This is NOT a pity party. This is the reality on how doctors are trained.

Until serious and considerable changes are implemented, the smart people will be doing their homework and will take a different career path.

I wish I had.

White Sands, NM

This place is so incredible. If you have never been, definitely put it on your list of must-see in your lifetime places.

Vacation

Wow, it has been quite a month. After surviving the swine flu I went back to work for just 4 days before heading to the Southwest for a week. It was awesome--a totally needed change of scenery. We got to chill out, eat good Mexican food, and to see some old friends. It was interesting to catch up with several people that I had met while doing my premed post-bac work. Most of my friends at that point were on the path to medical school or a related healthcare path. Now 5+ years after finishing, I am a resident. One other friend is a 4th year medical student after starting a PhD program and realizing it was not right. Another friend is now a PA. Someone else works in a lab. Two others have done some combination of high school science teaching/travel/other random jobs and are still thinking about going to graduate school, though not medical school. Granted, we are all a pretty non-traditional bunch, but it is pretty interesting to see where everyone ended up in the end.

I got back to work and have been enjoying my elective time. Elective months are nice because they give you time to catch up on everything else that has been lagging. I have been pretty focused on a research project and am wrapping up a manuscript and a couple of abstracts. At the same time it is hard because we are supposed to be learning important material on electives. In a couple of days I go back to my 80-hour weeks on surgicals, so I will definitely miss this time. Time to go to dinner with the family, but I will post some cool vacation pictures later.

The Swine Flu Diaries: Urticaria

Thursday

Yes, you read that right: urticaria, or hives. No, it is not normally part of the swine flu disease course. But I got to experience it. Lucky me. Here is how it went down.

I awoke feeling a tiny bit better. It appeared the upper GI part of the illness had resolved and it had settled in my lower GI tract. Not that diarrhea is fun, but I'll take it over vomiting. I took my morning dose of Tamiflu, drank some water, and flopped down on the couch feeling fatigued, achy, and out of it. About an hour later I had to make a run for the bathroom. Upon finishing my business there, I happened to glance in the mirror. What the hell? Why is my face so red? Looking more closely I realized that my face was covered with red wheals. I glanced under my pj's and realized they were all over my body.

I woke Mrs. Lone Coyote to tell her I thought I was allergic to Tamiflu. Boy, was she having a rough week with me waking her up with all kinds of problems each morning. We agreed it had to be the Tamiflu since I had not eaten in days. My airway felt fine, but the hives were growing bigger and itchier, so I grabbed my EpiPen just in case.

Eventually, a trip to my HMO was in order and a friend drove me over there to get some antihistamine and to show them my airway was fine. The several hours spent out just wiped me out and I eventually came home, took the antihistamine, and basically spent the rest of the day passed out. All of this meant no more Tamiflu for me. I would have to brave what was to come without the wonder drug.

The Swine Flu Diaries: The GI Phase

Wednesday

I awoke on Wednesday morning with a sense of urgency I have not felt in years. It was time to sprint for the bathroom.... now! Unfortunately, I did not quite make it, and Mrs. Lone Coyote was awakened by yours truly vomiting in the kitchen sink. Thus, a new phase of the badness had begun. The fever came down a bit. But now the evil pig virus had taken up residence in my GI tract. I spent much of the day making frequent trips to the bathroom where my body tried to force the little bit of water and Gatorade I was drinking out either side. Yes, you read that right. This wonderful virus features both vomiting and diarrhea as symptoms. Really fun times.

The body aches and headache were still there. I also was beginning to get a really bad sore throat. And I was so weak from all of the activity that it was hard to even sit on the couch for bad television. Remember that thought I'd had the previous day about how slowly could a day pass? This day was sinking to a new low.

And then our prince charming rode in on his white horse to save the day. Well, not really. But our primary care physician did call and suggest we start Tamiflu to provide a quicker resolution to the whole disaster. I was right on the cusp of the 48-hour widow for symptoms, but he thought it was worth a shot. A few hours later we had Tamiflu dropped off at our door by some kind folk who fetched it for us so we would not infect any more people at the pharmacy. We took our first capsules and I instantly felt better. Gotta love that placebo effect, or just a natural lull in my GI misery that happened to coincide with this capsule. Help had arrived.

The Swine Flu Diaries: The Constitutional Phase

Tuesday

It was very early Tuesday morning. After the realization that I was really sick on Monday night, Mrs. Lone Coyote had made me a nice meal and tucked me into bed. But I could not sleep. My lower back was killing me. It was this odd pain, right in the middle of my back, that did not get better with position changes. It felt like a pig was standing on my back, digging its hooves into my vertebrae, and taking revenge for all of the bacon and carnitas I have enjoyed in the past decade. And the fever was out of control. I was burning up, sweating through my pajamas, and shaking with chills. It was awful.

As I dozed in and out of consciousness, I suddenly realized that Mrs. Lone Coyote was up and taking her temperature. Oh no, she now had the flu too, and seemed just as miserable as I was. While I was really sad that I had given her this badness, I was secretly happy that I might have some company staying home.

Misery loved company indeed when we finally got out of bed. Tuesday was spent with both of us flopped on the couch, sweating and groaning, mindlessly staring at DVDs of The L Word all day long. Boy, that show has just gotten terribly melodramatic and tedious in its later seasons. But I digress.

Remember that headache I'd had the previous day? It morphed into a monster that took over my entire head and neck and that Tylenol would not touch at all. Even my eyes hurt. And then there was the nausea that seemed to accompany it at all times. I have never had migraines, thank goodness, but if they are anything like that headache, I can maybe begin imagine the suffering that they cause.

We were in hell on the couch and nothing could was making it any better. Every fiber of my body ached and burned. I tried to stay hydrated and finally emailed my primary care physician inquiring about getting some Tamiflu. Could a day pass any more slowly than this one, I wondered?

The Swine Flu Diaries: So It Begins

Monday

I woke up exhausted but thought nothing of it since I was on call and had worked much of the weekend. It had been hot as hell and hard to sleep in the heat. Grumbling, I threw on my scrubs, grabbed my chai, and raced out the door. It was a signout day for me, so I got in and busied myself getting my cases in order and tracking down missing slides. Even after the chai I had a headache brewing, so grabbed some Tylenol from the communal painkiller bins on my way to signout. "Gonna be one of those weeks, huh," one of my colleagues smirked at me. "Yeah, looks that way," I said. I had no idea what was coming.

It was my last day on surgicals and I was hoping to have a quick signout with not a lot of cases hanging over into my elective month. However, it quickly became clear that many of my cases were not as straightforward as I had hoped. Most of the morning flew by as we were engrossed by cases. I barely noticed that my head still hurt a bit and I was surprised to learn it was lunchtime as I was not that hungry. But I had some very nice tofu and brown rice and it was back to work.

About mid-afternoon things really started to drag. Or at least they seemed to. My headache had gotten worse. It seemed almost like I had not eaten enough for lunch and was hypoglycemic. I felt scattered and exhausted, but chalked it up to the end of a hard month and a rough day. Signout is pathology's equivalent of rounding: presenting patient history, getting pimped a bit, learning about findings. If your head is not in the game, it gets very, very painful.

By the time signout ended in the early evening I was starting to think something was wrong. I was chilled, the headache was even worse, and I was starting to have body aches. Still, I told myself, I would feel better if I could go home, go to bed early,and catch up on sleep. I forced myself to dictate all of my cases, clean out my work space, and move my stuff to prepare for the new rotation starting the next day. Driving home from the hospital I began to sweat, to feel nauseous, and to have rigors. Now I knew there was something really wrong.

The thermometer sealed the deal when I got home. 102.2 degrees F. "Crap," I said to Mrs. Lone Coyote, "I think I have the flu." Time to call my chief resident and collapse into bed. And so the influenza odyssey began.

The Swine Flu Diaries: Prologue

I have spent the last six days completely knocked out by influenza. Based on my symptoms and the infection patterns locally, I was told that I most likely had H1N1. But given that the treatment is the same, no one was going to bother to test me. As the fog slowly dissipates from my brain, I thought I would try to piece together the events of the past week. Hopefully, it will be entertaining and can shed some light on the virus that has recently captivated the public with its with dire pandemic predictions. So fry up some bacon, sit back, relax, and enjoy my swine flu tales of woe.

At the Cafeteria

It was going to be a late night for me, so I decided to head down to the cafeteria to spend some of my food allowance at the salad bar. I got my salad and a drink and headed for the registers. Being almost 8 pm there was only one register open and a long line. I got in line behind a very tall guy who was wearing special monogrammed scrubs that only certain people in the OR wear.

On a side note, there are so many different colors of scrubs in the hospital, that I cannot keep them all straight. Most residents tend to wear the standard issue scrubs from the scrub machines.

Anyway, I was standing there, sort of spacing out and watching a mom with some cute kids by the napkin dispensers. All of a sudden I hear "whoa, you snuck up on me!" It took me a minute it realize it was the tall guy in front of me, sort of peering down with this strange look on his face. I guess I was short enough that he did not notice me get in line behind him? He eyed my scrubs and my badge and said, "ah, you're sneaky, you must be an anesthesiologist!"

Puzzled, I responded, "uhh... no, I'm not an anesthesiologist." He looked surprised. "You aren't," he asked. "Uhhh... no, I'm a pathologist," I said.

His eyes lit up and he broke into a big grin. "Ahh, pathology, that explains it," he said. "Then you're sneaky and creepy!"

Must-Read Article

Strained by Katrina, a Hospital Faced Deadly Choices

The New York Times Magazine has a riveting account of what happened inside New Orleans' Memorial Medical Center during Hurricane Katrina. It raises a ton of ethical questions that I hope to never have to think about on the spot. But the reality is we all may have to someday. This is definitely one of the more thought-provoking medical articles I have read in awhile.

Formalin

In anatomy lab in medical school I remember being told that breathing in the vapors for hours while dissecting our cadavers could make one feel hungry. It did seem to work for awhile. Not anymore. There is quite a lot of unused money on my food card these days. Now I spend so much time around formalin that I can smell it long after I leave the gross room behind for the day. I'll be at home and get a quick whiff, even after showering. It is very bizarre, and probably not a good thing.

States Update

I was just trying to tally up all of my travels around the U.S. and found a new map for tracking. 40 down, 10 to go. I have vacation in a few weeks, but I am going to re-visit some of my favorite destinations in the Southwest, so I doubt I will knock anymore off. Louisiana would be a long drive away.


visited 40 states (80%)
Create your own visited map of The United States or vertaling nederlands duits?

Musings...

On Residency
I have been working a lot these days. If anyone reading this is wondering whether pathology residency has great hours, the answer is sometimes. But at most programs a lot of time will be spent on rotations with much longer hours, like surgicals, hemepath, and even autopsy and blood bank at some programs. It is very hard to work a 14-hour day and come home and crack open the books you need to read to really get a handle on the material. Pathology is a much more reading-intense field than many others.

On Blogging
I wish I had time to write more. It is such nice stress relief. But it has been good to see that some of the bloggers whose stuff I enjoyed, ie Panda Bear, The Fake Doctor, are back in action. Bostonian has a nice post detailing some good reading if you want to catch up.

Pathology Humor

:::A piece of tumor falls off the grossing table and onto the floor:::

Resident 1: Dude, you dropped your tumor.
Resident 2: Oh, crap, I did.

:::leaning over:::

PA: Quick, 5 second rule!
Resident 2: It's not too late.

:::grabs tumor with forceps:::

PA: Anyone have a Triscuit?
Resident 1: Soft tissue appetizer, anyone?
PA: Yippee, mystery meat!

:::laughter:::

Yeah, we're a bunch of sick f-cks. But it does make the time go by quicker.

Conversation Killer

I finished autopsy. Well, at least this round of it. There will be a few more months coming up in the future. I'll let you in on a little secret: most people in pathology do not like autopsies. There seems to be this assumption, especially among other doctors, that we must love autopsies. Some people do. If they really do they might go into forensic pathology or take an academic position at a place where a lot of autopsies are done. But many do not, and in this day and age of declining autopsies one can generally find a job where doing them is rare.

Long ago I blogged about what happened when I told people that I was a medical student. Now I can tell you that announcing you are a pathology resident inspires even more weird awkwardness. "Oh, like on CSI, right?" "Pathology?" "Oh, that must be interesting." Or (usually from people with some knowledge of the health professions) "hmmm..." with a stare that implies that I must be social inept/lazy/a serial killer/all of the above. And occasionally, usually from really burned out residents/clinicians, "you are so lucky you made the right choice: no patients, good money, and nice hours."

But imagine the conversation either: 1. actually progress beyond that initial phases or 2. is with someone I know who knows a bit about what I am doing. Now someone asks what I am doing right now. "I'm doing autopsies." Can I just say CONVERSATION KILLER?

Remember what I said above about CSI/social ineptitude/serial killer associations? It all comes back right in that moment. The look of horror comes up. Awkward silence reigns.

Or, the other alternative usually occurs with people who have had some medical training. I am not talking about other MDs. Most MDs I have talked to go into the horror camp, though they don't react as strongly. These other folks react with this very genuine "that must be so interesting!" They then launch into a ramble about how cool it must be, and then suddenly will say something like, "I know it is morbid but I have always wanted to see an autopsy." If the person works at my hospital I usually tell them it could be arranged. I wonder if anyone will ever come and watch one, and would it really be that interesting?

1 Week to Go

3 weeks of autopsy down and 1 to go. We have been really, really busy this month, and are getting close to setting a record. Welcome to July. Argh. There have been some really interesting, rare cases. But overall it has just been exhausting. Next month will be even busier, so it's time to ramp up. I am hoping to wrap up my current cases this week. Unfortunately, autopsies take a long time to resolve since getting slides, records, and writing reports can take weeks. So any cases we pick up this week will follow us onto our next rotation and will have to somehow get done amidst everything else.

In other news, Daisy of Love wrapped up last night. I won't spoil it in case anyone reading this cares, but it was not a huge surprise. The next installment of VH1 reality love show trash starts this Sunday, I believe, with the kick-off of Megan Wants a Millionaure, featuring the ever manipulative, aspiring trophy life Megan Hauserman from Rock of Love. Yes, I am sinking to new lows in TV watching this year... I knew it was bad when one of the big queens at the gym was shocked when I mentioned Daisy of Loveand said, "girl, I had no idea you watched that!" But hey, talking about this crap with colleagues makes the autopsies go by quicker and it sure is a more fun way to spend my evenings than reading pathology texts when I am exhausted. Okay, time to go watch the Charm School season finale.

Bravo Wisdom

So I must admit that I have become addicted to Bravo reality shows. I used to just watch them sporadically. But since residency started last year, they have become a really nice way to zone out at the end of a long day. Besides, who wants to do something like read about fetal cardiac malformations when you could watch unsuspecting wealthy people from around the country be made into complete caricatures on national television?

Tonight was the first episode of "Miami Social," Bravo's latest installment in their showcase of urban high life vapidity that is immune to the poor economy. This show, with its constant parties, clubs, dating drama, and sex talk, really took the cake for shallowness. It made the various "Real Housewives" series, that addressed some "real" topics like drug addiction, cancer, and parenting amidst the superficial drama, look downright deep. I should probably stop now while I am disgusted and not get roped in. But somehow I have this awful feeling that next Tuesday night, when given the choice of reading a pathology book or TV, "Miami Social" will win. I'll leave you with a few choice words of wisdom from the crew:

Oh my god! I look so good in this reflection.

Never break your shoes over a man.

When people are in love, they get fat.

Poor Pepper

Linda Splits Gay Peguins

From the Morgue

Yes, I am doing autopsies. What a way to start the new year. We have been busy... could it be because it is July?

I was waiting for the elevator this morning and there were two patients standing near me. One pointed to the fading sign that has hung near the elevator for the last 2 weeks: "New Resident and Fellow Orientation (up arrow).>

"This is why you never go to a teaching hospital in July," he said to his companion.

"Huh, why not?"

"Because July is when all of the new doctors start and they don't know anything. They might kill you."

Could this be the reason why we've been dissecting for ~12 hours a day this week? Or is it just because July is a big month for teaching and autopsies are a good teaching experience? Or are all the newbies just gung-ho about consenting families for autopsies? Food for thought.

The End of Intern Year

The clock is ticking slowly today. I mentally checked out awhile ago and am just going through the motions at this point. There are a few things to follow up on, a nice signout sheet to make for the incoming resident, and I am done.

I headed over to Starbucks at lunch time to buy myself a little treat for my last day. There was quite a line snaking out the door, so I settled in for a wait. As we crept up a bit I was standing in front of the pastry display. All of a sudden there was a crash and a plate of coffee cake that had been balanced on top of another coffee cake display fell off its perch and lodged itself precariously against the edge of the display case.

One piece of coffee cake got stuck with the top edge of the plate bisecting it in half. That piece of cake started to stretch, and stretch, and stretch. Gravity was pulling it towards a free fall to the bottom of the display case and it was holding on with all of its might. It literally took a couple of minutes for that cake to stretch itself to the point of breaking. When it finally fell the people in line around me and I all started laughing. "That was the most exciting thing I have seen all day," said the elderly woman behind me. "But maybe that tells you something about the kind of life I lead."

Perhaps. But the trajectory of that coffee cake pretty much sums up these last few hours for me: a very slow march to the moment when intern year will plummet into the repository of past life experiences, where it will sit like a smushed piece of coffee cake against the glass, bruised yet visible, and certainly not forgotten.

One Day + One Hour to Go

Could it really be about to end?!??

4 Days To Go

My medical school buddies are all done with their intern years. Congratulations everyone! But me... I still have 4 more days to go, including today. This is what I get for having an extra week off last June to chill out and unpack from my move while all of my friends were already busting their butts in the hospital.

But there is one perk to this "extra week." Yesterday I started to realize that I was getting some strange calls and requests that did not make much sense. A couple of the callers seemed completely lost. Suddenly I realized that I was talking to new interns and that I sounded like I really knew what I was talking about. I was actually able to teach someone something! What a new concept. Perhaps I could get to like this second year resident role. I won't jump ahead of myself here, but I am going to try to enjoy my last 4 days of being a "super" intern.

That Light Is Getting Brighter...

I saw a flier directing people to the "New Resident and Fellow" orientation today. This is my last full week of the year. 6 more days to go. And it could not be coming soon enough. Not that my current rotation is so horrible, but I am just done. So done. So very done.

I had a moment last week where I realized the year really needed to end. I was at home after work and I went to grab a container of yogurt-covered raisins out of the pantry. The lid was not fully on the container and all of the yogurt raisins (we're taling at least 100 in the nealy full package) cascaded down to the floor and rolled everywhere. I laughed my ass off until I almost cried. Mrs. Lone Coyote looked at me and was like, "what is going on?" I could not stop laughing. Finally, I was like "this is the best thing that has happened today." It truly was.

When the highlight of your days is watching white candies bounce onto the floor, you know it is time for the year to end.

Beware of Popsicles

This one really takes the cake for strange calls. Courtesy of an attending:

Clinician: Hi, I have sort of a strange request.
Lab resident: Okay.
Clinician: Can you run a creatinine on a popsicle?
Lab resident: What?
Clinician: Can you run a creatinine on a popsicle?
Lab resident: Uhhhh...
Clinician: I know this sounds really weird, but we have this patient who thinks that the neighbor is trying to poison her kids by feeding them urine popsicles. We thought if we could run the test on the popsicle, we could prove that it is not urine.
Lab resident: Sorry, no, we aren't doing that.

T - 13 Days

The end of the year is getting closer and closer. Yet it seems so far....

Anyway, in honor of my last call night of the year tonight, I thought I would start posting some of my favorite call moments of the year. Some of them I have experienced, and some of them were other's tales of woe. Hopefully, they will be entertaining.

Tissue is the Issue

Caller: Hi, is this pathology?
LC: Yes it is.
Caller: Do you do biopsies?
LC: We do FNAs.
Caller: FNAs?
LC: Fine needle aspirations?
Caller: Is that a biopsy?
LC: Uh, not exactly. It's a needle biopsy. We run a small needle through the mass and draw up cells for cytologic examination.
Caller: (accusatory) That's not a biopsy!
LC: Yes, it's not a traditional tissue biopsy.
Caller: (Raising the voice level) But you're pathology. You're supposed to do biopsies. Isn't that what you do all day?
LC: Well, we do look at tissue sections. But generally someone else gets them for us.
Caller: (Yelling) Well, what am I supposed to do now?
LC: I suggest you call IR or surgery depending on what you are trying to biopsy. What kind of mass does yur patient have?
Caller: :::hangs up:::

A Little Tip From Your Friendly On-Call Lab Resident

I know you sometimes may be frustrated when we tell you that a certain volume is required to run a test. Really, we are not telling you we cannot do the test just for our own sadistic pleasures. Sometimes we literally cannot set a test up if you submit the specimen improperly. And, no, you cannot combine samples from past draws to achieve the desired volume. Sorry, I am going to have to say no that one.

Staircase Blues

The main stairwell in my hospital was very poorly designed. It is very narrow and accomodates about two average-sized people across its width. In the day and age of Americans of increasing body size, this type of design can be very problematic. One person moving slowly up or down the stairs can cause a massive back-up in both directions if no one can get around him. Around the floor that the cafeteria is on near lunchtime there are routinely traffic jams.

Additionally, at each floor the doors to the floor open outwards into the stairwell. Did I mention the door are heavy metal firedoors with no windows? And the landings are tiny? This means that as you are coming up or down you always have to be on the lookout not to get wacked in the face by someone swinging open a door.

So if you work at the hospital one would think that you get used to staying as close to the railing as possible, moving quickly, and swinging wide to avoid doors. One would think you would also learn that you have to walk single file behind your colleagues so as not to block traffic or have a collision with someone running up or down the stairs on the other side. But I guess that would be too much to ask for. Every trip on the stairs is an adventure, so I have started to categorize some of the staff stairwell behavior that never ceases to amaze me.

"The white herd" - this would be an entire team clad in white coats, usually Medicine, rounding in the stairwell. This involves standing around, often outside the radiology floor on the tiny landing, arguing some point of clinical minutiae and being incredulous when people are trying to squeeze by them.

"Best friends" - this involves a group of nurses and other hospital staff, usually female and on the way to lunch. They slowly move in a flock taking up the entire stairwell and preventing anyone from passing in either direction.

"Important people" - can usually be seen leaving the surgical floors and moving very rapidly. They tend to move in pairs and are never single file. Get out of their way, especially if they are headed for the cafeteria, because they might trample you.

"I hate my job" - these people move very, very slowly, especially if they are returning from break. Often they can be heard on their cells complaining about "that girl" or "that guy" on their floor or how unfair it is that they got their lunch at X time today instead of Y time. If you get stuck behind one and there is tons of traffic the other way, expect to be climbing stairs for awhile.

"Passive aggressive" - a subset of "important people" who run up behind you on the stairs even if it is clear things are moving slowly. They may even step on your heel not realizing that tailgating doesn't move traffic along.

"Door monsters" - usually late middle-aged folk who always swing the door open quickly and nearly take you out. "Oh, I'm sorry," they say sweetly as if after working here for 20+ years they do not realize the doors can take people out on the stairs all the time.

More to come, I am sure, as I continue to take the stairs.

28 Days to Go

Now that I have made it to June, I am finally allowing myself to begin an official countdown to the end of this year. Unlike many of my friends, I do not get a week off at the end of "intern" year and will just roll from one service to the next to un-ceremoniously start my 2nd year.

Currently, I am doling out blood products for patients. Blood Banking is its own field within pathology and it is pretty complex. It goes way beyond ABO and criteria cut-offs for issuing products. There is a ton of medicine here, more than I have done most of the year. Some of the more difficult cases are actually fairly interesting. Most of my day is spent writing up transfusion reactions. Blood products are not benign and in some cases we all need to be sure that we have a good reason for giving products and are not just treating a number. Luckily, most of the reactions are the garden-variety allergic reactions which are unpleasant for the patient but not life-threatening. Then there are the badder actor--hemolytic reactions, TRALI, TACO. They do happen.

In other news, it looks like health care reford is coming to center stage in Washington. If you are interested in health policy, check out this piece by Atul Gawande.

I love FAIL blog

see

T - 6 Weeks and Counting

I am back from vacation. It was a lot of fun and SO great to be away from work. Once I get my pictures together I'll try to post a few. I came back to piles of work, as usual. But, I had an amazing revalation when I looked at my calendar this morning and realized that there is less than 6 weeks until July 1 and the end of this year!!! I read a collection of short stories awhile back that traced an internist's journey through residency. One of them was about checking boxes and counting down. She reflected on how her life had basically become a tasklist and a countdown: how many more things to check off before I can go home, how many more days on this service, how many more nights on call, how many more months until residency ends, and so on. How right she is.

The Medical Home

I've been hearing a lot about the "medical home" model lately and I honestly have not been very clear on what it exactly is. It seems to have started to get more press about the time I hit my "senior slump" and stopped doing medical student rotations with much content other than leaving by noon. This video provides a good, short introduction to the concept, and Wikipedia also has a basic article.

Overall, it seems like the model has some potential to make the primary care experience better for patients and physicians alike. It was interesting to learn that the model seems to have originated out of pediatric practices caring for children with chronic illness. The experience I had in medical school that came the closest to the "medical home" model was the month I spent on outpatient pediatric heme-onc. Multiple people saw the patient and his/her at the visit: physician, infusion nurse, and social worker were key. Then others like physical therapists, speech therapists, nutritionists, other specialists were added based on the child's needs. Translators were always available, usually in person. They seemed to do such a good job of addressing everything that some parents said they felt no need to see the general pediatrician for routine visits.

So I wonder if this model could be a good way to go in the future. I have no doubt that the electronic medical record (EMR) can help dramatically in coordinating care. Having spent a good chunk of time this year at a hospital where most clinics still did paper charting, I came to see how frustrating it could be to have no way of finding out anything about a patient in a timely manner. I do not think that EMR is a magic bullet that will save the system; there are many problems with cost, implementation, and coordinating EMR across different health systems that will need to be addressed over time. But it does seem helpful at providing an accessible record for all that care for a patient within one system.

Bringing in nutritionists, PTs, psychologists might be a way to help chronically-ill patients make lifestyle changes, and could help to ease the burden on primary care physicians who do not have enough time to address these issues at routine visits. Group visits and classes could also help to shift to a more preventive focus. Kaiser offers a lot of classes for patients with chronic illness, who are going to undergo routine surgeries, for child-birth and parenting, and even preventive health classes for the "average" person. Feedback I've heard from people have attended these has been mixed, but overall positive. Of course, there is instructor variability to take into account. But Kaiser does seem to have made progress overall in reducing death from heart disease (it's in all of their ads, but if you want to know more, start on p. 20).

I'm not really sure what the medical home would mean for specialists. Would it make referrals easier? What about for hospital-based physicians? Could it improve care after discharge, which is said to often be a critical time for patients? For those of us in diagnostic specialties it seems it could help with coordinating procedures and getting results to patients in a timely manner. How helpful it is it turn around a biopsy rapidly if the patient, who is anxious and stressed that he/she may have cancer, cannot access anyone to give him/her the results?

I am sure we will hear more about the medical home in the coming months as health care reform takes center stage in Washington. It is clear that we need some drastic changes in our delivery of care in this country. Is this one of the answers? I'd be curious to hear your thoughts.

Home Call, Take 2

So I tempted fate blogging about home call while I was on call. It has been a really busy week. We've just been swamped. And I am really ready for a day off after working for days and days in a row. Luckily, I get my last week of vacation next week. I am SO excited.

Anyway, back to home call. Basically, you're sitting around waiting for the pager to go off. Depending on how heavy your home call tends to be, it can be a quiet night at home answering a couple of random pages here and there, or a total nightmare where you are basically working non-stop from home or going back into the hospital. When you have the heavy nights where you are up all night, there is no "post-call" day to recover. You go into work and work another full day. And if your program does long blocks of home call, you might be on call again that night and the next and the next.

Another thing I have discovered about call from home is that it makes it harder to get things done. There's something about paging someone back to a number outside of the hospital that seems to make it take longer for your pages to get answered, if they ever are. Computer access can be a nightmare depending on your hospital's system. You have no back-up nearby. If you do not know what to do, or just want to run a plan by someone, you have to call someone else, most likely your attendings. At 3 am you may not want to call them because as much as they say they are there anytime, they will not be happy to hear from you then.

Call From Home

Since I am on call right now, I thought this might be a good time to discuss taking call from home. On one hand, I am really not complaining that I picked a field where I do not have to do q4 overnight call in the hospital. I am thankful for that on a daily basis when I interact with exhausted interns and residents.

But on the other hand, call from home is really not what it is cracked up to be. It sounds benign enough--you sit at home and get to answer calls from the comfort of your couch. If something is urgent, you go in. Or at some programs being on call "from home" also has some set time that you spend in the hospital each day. So you might work basically a full day and then go home and take call. However, you were technically on call "from home" all day, so none of the work you do counts towards duty hours. Pretty sneaky, huh?

Being on call from home has its drawbacks. You are basically stuck at home because you cannot go too far away in case you have to go to the hospital. Access to a phone and computer are needed at all times, so that eliminates things like going out to dinner. I guess if you had an I-Phone you could pull it off, but then you have HIPAA to think about when discussing cases in public. So you sit at home and wait for the pager to go off. And there goes my pager. How ironic. More on this later.

Buried

Wow, it has been awhile since I have blogged. I have been buried by work on my current rotation. It has been interesting and I have learned a lot. But I will be glad to see the 2 months come to an end and to get to move on to something else. There is a lot going on in the world of health care right now--swine flu, Obama's plan for reform, and an IOM report uring MDs to stop taking gifts from drug companies, just to name a few. Perhaps I can discuss some of those issues later.

But I bet that you did not know that last week was National Medical Laboratory Professionals Week. This years theme was "Laboratory Professionals Get Results." Cute. I would not have known about lab week either except that I was surrounded by the festivities. For me that meant grabbing some cheese, fruit, and ice cream from the many free lunches that occurred and running back to work.

In a way it is kind of sad that no one outside of the lab really knew about lab week (except, of course, for the staff from a neighboring department who crashed every event to take free food). Over the course of this year I have come to realize that few people really know what goes on in a clinical laboratory most of the time. I am included in this too despite having done a rotation in "lab management." To sum it up very briefly it takes a lot of staff, coordination, and regulation to keep all of the machines and tests putting out high quality data. The laboratory professionals are highly skilled and there is a huge shortage of them nationwide. Better publicizing lab week might be a good way to call attention to the shortage, to help everyone in health care better understand what it is exactly that laboratory professionals do, and how essential they are to providing good patient care.

The Bathroom Files

Who knew that the bathroom could be such fodder for blogging?

When we last left off, the Lone Coyote was celebrating the fact that she had finally conquered bureaucracy and gained access to the vaunted staff bathroom. Trust me, celebration was warranted given the other options for restroom access in the vicinity. But after about a week of staff bathroom access, I have concluded that strange things can occur in hospital bathrooms. And apparently I am not alone in my observations. Three colleagues and I spend a good 20 minutes yesterday sharing bathroom stories, laughing, and feeling generally grossed out. Here are a few of the highlights:

The Hiders: the staff bathroom clearly serves as a hideout for employees who do not want to do their work. Several times already I, or another one of my colleagues, have entered the bathroom to find all of the stalls full. The feet can be seen underneath. We wait. And wait. And wait. No movement occurs. No sounds are emitted from the stalls. Even exiting and returning a few minutes later does not seem to change anything. They are on a long bathroom break.

The Toilet Paper Tsunami: by the end of the day their is always a humongous pile of toilet paper and seat covers on the floor of the stalls. They aren't dirty, just strewn about in a pile. I am not sure what the appeal is of throwing paper all over the floor, but clearly someone has a fun time.

The Beauty Salon: I also noticed that there were often large puddles of water all over the counter and the floor near the sinks. We are talking lakes here, not little splashes. According to one of my colleagues, she had wondered about the origin of the daily puddles too until one day when she walked in and found a couple of staff members washing their hair and generally "washing up" at the sinks. You'd never know there is a staff locker room with showers that can be opened with the same key card right across the hall.

All of this in just one week. And I'm sure there will be more to come.

When You Gotta Go, You Gotta Go

On my current 2 month rotation, I was rather distressed to find that bathroom access was a challenge. Near the lab is a "Staff Restroom" with card key access. Of course, my card did not open the door. I would have to stand in the hallway and wait for someone to walk by, take pity, and open the door. More often than not, I would have people pass by and look at me like, "why can't you open the bathroom, there must be something wrong with you," and dart away. Ironically, my attending cannot even get into the bathroom and was once berated by a staff member about not being able to open the bathroom door.

I decided this had to be dealt with and found out from another resident that the security office could fix all of my problems. Thus, I embarked on journey to the basement where I was told to "send an email." See below for the rest.




-----Original Message-----
From: The Lone Coyote
Sent: 4 Days Ago
To: Security
Cc: Another Resident
Subject: Access to restroom/locker room

To Whom It May Concern:



Who needs access? The Lone Coyote, MD and Another Resident, MD

Where? Women's Staff Restroom/Locker Room

Why? So that we can have a bathroom to use.



Our Supervisor: Program Director, MD.



Thank you for your attention to this matter.



The Lone Coyote



The Lone Coyote MD
Resident
----------------------------------------
From: Security
Sent: 4 Days Ago
To: Some Supervisor Deep in Bureaucracy
Subject: FW: Access to restroom/locker room



Is she ok for womens locker room access?
------------------------------------------
-----Original Message-----
From: Some Supervisor Deep in Bureaucracy
Sent: 2 Day Ago
To: Security
Cc:
Subject: RE: Access to restroom/locker room

Sure, this is fine.

Thanks,

Supervisor
------------------------
From: Security
Sent: Late This Afternoon
To: The Lone Coyote, MD
Subject: FW: Access to restroom/locker room

Done.


Woohoo!!! We can go pee in style now.

More Elevator Adventures

Overheard in the elevator... not the same one I wrote about the other day.

Nursing student: (pushing button)
Nurse: No! Not that one. This one. (points to another floor)
Nursing student: I'm sorry.
Nurse: You can't even go to that floor. (points to button student originally tried to press)
Nursing student: Why not?
Nurse: You need a special key to get off there. The babies are there. The babies have to be kept safe.
Nursing student: (nodding) Yes, that is very important.
Nurse: (snorts and rolls eyes at student) I really don't see what the big deal is. I mean that is the ICN. That's where all the super-sick babies are. They're in bad shape. Many won't make it, and if they do, what's the point.
Nursing student: (looking stunned)
Nurse: I've always thought if you want to steal a baby, those babies are not good specimens. You should try the Well Baby Nursery. Those are worth it.

And with that they reached their floor, which houses adult patients, and got off.

Elevator Adventures

We were coming back from a bone marrow biopsy today when our elevator was "captured for hospital emergency." Wow, "elevator capturing" sounds like it could be some new extreme sport or an event at a rodeo. But it's really not that exciting. Basically, it means that the elevator is needed to transport a critically ill patient, usually from the ED to the ICU, and someone with a "code key" uses his key to call the elevator directly to a specific floor.

We exited the elevator at the ground floor to let 2 nurses push a patient and numerous beeping machines into the elevator. Then we waited. And waited. And waited for another elevator to come. Soon there was a whole cast of characters waiting with us. Nurses, respiratory therapists, physical therapists, clerks. Everyone was chatting it up and expressing annoyance at the slow elevators. Finally, an elevator arrived and all fourteen or so of us piled in. I was in the way back of the elevator smushed in next to the lab tech with the bone marrow tray. Let's just say it was a very tight fit.

We go all of one floor up and the door opens to reveal a food service worker waiting with a huge steel cart full of patient lunch trays. There was no way in hell that this food cart could fit into the ~2 square feet of open space left in the elevator. But she was going to try. She started pushing that steel disaster towards the elevator and a man by the door said, "no way, not going to fit." The lady got angry and shouted, "this is for patients, I need the elevator, get out!"

Everyone was stunned and then a very quick thinking person in scrubs yelled back "We are all patient care in this elevator!" Several people started to laugh and one nurse yelled "goodbye" and pushed the door close button. The doors slammed, just missing the cart that she was still trying to wedge in to block the door, and we were off on our slow climb to the top of the hospital.

Diagnosing Bad News

I am feeling much better. Thanks for all of the comments. It's nice to see that people are still stopping by.

These days I am on a very busy hemepath service where I spend my days looking for leukemic blasts and the other abnormal cells that signal cancer of the blood and bone marrow. Inevitably, we get a horrible case at the end of a long day. It's hard to describe the sinking feeling I get in my stomach when I focus the scope and see blasts everywhere. Their monotony signals badness. Often the clinical team has arrived to see the case and everyone sits silently taking it in.

We apologize. We look around, hoping to see something that might change the diagnosis. But the badness is still there. For that brief moment before they have to run back to the floor we all share a collective sense of grief.

Sick Days

I have been sick this week. At first I just thought I had bad hay fever and was over tired from a long week at work and a weekend packed with social activities. But by Sunday night I realized that I just felt like crap. So I called in sick.

What's the big deal? I am in residency so calling in sick can be fraught with peril. My work has to be covered by someone else. In theory, if we miss too much time we could have to make up the days or the year might not count towards accreditation. Luckily for me we have an extra resident on service right now and I had covered some of his work when he was out last week. So I knew the coverage would not be a big issue. That doesn't mean I did not feel a sense of guilt about staying home for a day.

Overall, medicine as a profession does not take kindly to people calling in sick. Logically, this makes little sense. As physicians we should know that coming in to work with illness and exposing everyone around us, including patients, makes little sense from a public health perspective. We should know that we are not at our best when we are sick and that clouded thinking can lead to adverse outcomes for patients. And we do know that rest is essential to getting well. It is what we advise our patients to do. But somehow this all can get lost in our culture where work reigns supreme above all else and where we feel a sense of obligation to provide for our patients no matter what.

I doubt that any of this will change anytime soon. I know that I am guilty of participating in the culture myself. After spending a day at home sitting on the couch, I dragged myself in yesterday and worked a full day, despite people telling me to go home early and rest because I looked awful.

How can we make changes? We have to start by acknowledging that it is okay to take time off to get better if we truly are sick and convincing our colleagues to do the same. And systems that provide sick coverage need to be in place to allow people to take the time they need without feeling guilty and that they are burdening their colleagues. This can be especially difficult in residency where it is residents on "elective" and "call free" months who get pulled in to cover for sick colleagues. It will take a systemic shift in attitude, but a new perspective on sick days would be healthy for our profession.

It's Match Day!!!

Congratulations to all who matched today! Match Day is a definite high point of the whole medical education process.

It is hard to believe that just one year ago I matched myself. Things change a lot in a year. A friend and I were reminiscing tonight about excited we were then to get started in residency. Now almost 9 months through this year, well, let's just say some of that shiny, excited feeling has worn off.

But, a nice thing abut being on this side of the Match is that it means that a new class of people is coming in. That means that I get to move up on the ladder. The end of the first year is now finely coming into view.

Playing With The Big Kids

Medicine is very hierarchical, especially during medical training. At the top are the attendings, then come the fellows, the upper level residents, the interns, and finally the medical students. The structure is more rigorously followed in some specialties and locations (ie Surgery, the East Coast) than in others. I have been lucky to train at places where things are a bit more relaxed in general, so as a medical student I could talk to an attending without going up the chain of command if needed.

However one feels about the structure and its nuances, it can be rather comforting to have in place. It starts from Day 1 of medical school. We were assigned a "big sib" from the 2nd year class who was there to answer our questions about what books to buy and how to study for tests. In those days the 3rd and 4th years seemed far removed and intimidating because they had "real clinical experience." Of course, the fact that they were on another campus most of the time probably added that perception.

Our "sibling" networks continued throughout medical school, and soon we were those "intimidating" students giving advice on how to schedule rotations to those below us, and asking our current interns about the different residency programs they had seen. There is something comforting about having someone who is essentially your peer available to answer all of your "dumb" questions and to calm your nerves about the next step when needed.

Then residency started and things changed. Don't get me wrong--I have great colleagues ahead of me in the program who have provided great guidance when needed. But one thing that is different about my field is that I have a lot of contact with attendings and fellows. They come to me to give them the answers on their patients. Let me tell you, it can be quite intimidating. Usually it starts okay because I have some idea of the case or the question at hand and can give them a basic answer. If I cannot, I will tell them upfront that I do not know, but will find out, and get back to them.

It gets harder when my basic answer is not enough and they begin the questioning, especially if it delves into more esoteric clinical realms. Let's think about this for a minute. I am not doing a traditional intern year, so my clinical knowledge is that of someone who graduated medical school. Actually, at this point some of that base has left my memory in favor of new knowledge, so I am on a decline. At that point of awkwardness someone higher on the totem pole than I will usually take over. It always amazes me how much my fellows and attendings know, and it seems impossible that I will ever be there also.

The whole experience reminds me a bit of being in kindergarten and riding the bus home with the 5th graders while I clutched my Care Bears lunch box and sat very quietly. I never thought I would ever be that big and that cool. But then one day I was, well maybe a bit shorter than they had been, but still I was there laughing and having fun on the bus home. So perhaps one day at the end of this I will make it to the top of the hierarchy and be able to show cases and answer esoteric questions with ease. Then it will be fun to play with the big kids. For now I think I'll just sit quietly, get my work done, learn via osmosis, and bide my time at the bottom of the trainee hierarchy.

Beware of Hospital Parking Facilities

What is it with hospital parking? Everyone complains--the patients, staff, physicians. Generally, it seems like a case of not enough spots for way too many people. In medical school I lived so close to the hospital that I never had to worry about parking. But that did not stop me from having my share of encounter with cars nearly running me over as I walked through parking areas, or near accidents caused by physicians racing out of the MD lot that was near the street I lived on.

Many of the patterns I observed there continue at my new institution. Only now I have to drive and am entitled to park in one of those "MD/staff only" parking areas. Being in the field that I am in where we do not do morning rounds, I get to arrive a bit later in the morning than many of my fellow residents. Thus, I get there around the time that tired people are leaving after working overnight and as many of the attendings are arriving.

Can I just say sleep deprivation, luxury cars with big engines, and arrogance are a really bad mixture? In the past week I have seen cars weaving towards the exit with the telltale open window of a sleepy driver, and been nearly read-ended multiple times by Lexus/Audi/BMW/Mercedes racing up behind me on the ramps in the mad dash for spots. In one case I looked in my rear view mirror and saw the driver making obscene gestures at me since I was apparently not driving fast enough in a narrow aisle with a 5 mph speed limit. I was very surprised he did not honk. But I was not surprised when I later caught a glimpse of his badge as we walked into the hospital. I'll leave his department to your imagination.

The moral of the story is drive very defensively when you go to a teaching hospital, especially if it is around shift change.

Work Hours Discussion

There are several articles in today's New York Times about work hours reform and some interesting discussion brewing on the comments section. It is the 25th anniversary of Libby Zion's death this week.

I have been wanting to write about work hours since there is a lot going on with the new IOM recommendations and the ACGME's response. But, ironically, I have been working too much to blog about it. So I'll let these articles wet your appetite and hopefully I can weigh in later this week on this rather controversial issue in medical education right now.

One Pathologist's View

I have been really busy this past week and sick on top of it. Thankfully, I am on a pretty light rotation where I was able to take a sick day and let my work pile up to deal with on my return. Anyway, I hope to get back in a better blogging groove soon. In the meantime I was interested to find this blog, Patience Lost - Lines from a Hospital Trench, which is one academic pathologist's thoughts on the state of pathology in the current day healthcare system. I must admit I have not had time to read the entire thing, but the bits I have read have been interesting. I hope to read through it all soon. It is always great to find other pathologist bloggers and writers out there.

The Physical Exam

Pauline Chen has an interesting piece in last week's New York Times about the role of the physical exam in modern medicine. I must admit that as a medical student I was often frustrated by the physical exam. Likely, some of the frustration was due to a lack of confidence in my ability to perform some of the maneuvers. With practice this got better. After a month with an FP physician with a passion for sports medicine, for example, I was not afraid of patients with lower back pain anymore. He taught me a nice formula with a few simple tests to do each time that covered the range of motion of the entire back and pinpointed the location of the injury. Repetition does work.

A great deal of my frustration, however, I now realize was brought on by certain aspects of my training itself. During our first year we were taught physical exam skills in our Doctoring course. The course was taught by an NP who was very skilled at the physical exam and emphasized its importance. Smaller, more specialized parts of the exam were reinforced in our 2nd years coursework relating to organ system. By the time we hit the wards, I was pretty comfortable going leisurely through the motions on my classmates and the mostly healthy patients I saw at the student-run free clinics.

On the wards things were different. Everything moved much faster and the patients were often very sick. Residents were overworked and focused on collecting the volumes of data necessary for following the patients imaging, labs, and vitals. It was what Dr. Chen describes--spending a lot time touching the patient became low on the priority list. In rounds the physical exam was not usually emphasized. It was often brushed over to focus on imaging results. If a medical student brought up some exam maneuver to attempt it might be viewed with amusement as a relic of the past or as a teaching point. "Oh, that, well we rarely use that anymore since it is unreliable and we can just look at the CT, but why don't you try it when we go in to see the patient."

There were some exceptions to this seeming cultural norm, of course. On Trauma Surgery the physical exam carried a lot of weight, especially since initial treatment decisions often had to be made immediately and could not wait for imaging. On the wards I had one Internal Medicine attending who is very much like Dr. Abraham Verghese, the physician whose work that inspired Dr. Chen's article. With this attending all of the medical students went weekly on physical exam rounds and listened to the patient's stories in great detail. It was interesting and usually a more rewarding way of seeing patients than the usual rush-in, rush-out. Unfortunately, it was only once a week for a small part of my 3rd year.

So as I look back on my training it does not surprise me that as a medical student I tended to use the extra time I had with patients talking to them and not on performing detailed physical exams. I felt I could contribute more to their care by listening to them, being supportive, answering questions they felt had not been addressed, building rapport, and maybe even by finding some detail in their history that might have been missed. Perhaps the physical exam, as Dr. Verghese suggests, is another avenue for building trust with patients and finding the missing puzzle pieces to make the diagnosis. And with more emphasis on its importance in medical education and more physical exam teaching at the bedside, maybe the medical students who come after me will not find it to be the sometimes puzzling and frustrating experience that I did.

T-2 Weeks and Counting

It's almost time for all of the folks planning to match in this year's Match to submit their final rank lists. I can hardly believe that just one year ago I was in the same boat. Trying to figure out which residency program will be the best fit for you can, if you are lucky, be quite simple. Or, for many people, making the final decision can be rather difficult.

We had someone come back for a second look at my program today and I was one of the lucky few who got a free lunch at a posh restaurant to answer the applicant's questions. Being on this side of the matching process I can honestly say that I have no investment in what people decide to do. Of course, I would like to have friendly, hard-working people come to our program. But I also know that decisions are highly personal and take into account many factors, which often are about more than just the program itself. For example, last year I visited a program that I knew throughout the interview day would be perfect for me and my career goals. I clicked with the faculty and the residents, loved the hospital and the patient population, and thought the program structure and schedule were among the best I saw. But it was in a city that I knew we would be miserable living in, so it went lower on the rank list than it would have gone bases solely on the program.

Making my final rank list was difficult and caused a lot of stress, especially in the last couple of weeks. Based on my experiences last year interviewing/matching, my residency so far, and the experiences of some who have come before me, here are a few thoughts on trying to figure out how to make the rank list.

1. Relationships. Yes, this is about your career and getting good training so that you can become the best doctor possible. But it is very important to be happy and supported outside of work too. And maintaining relationships, of any type, in residency definitely takes work given the constraints on your time. If you have a spouse/ significant other, take his/her feelings into account about where he/she would like to end up. If you are single and hoping to meet someone in the next several years, you may want to consider how hard/easy it will be in the location of your program. Having friends/family to hang out with, especially, those who are not in medicine, can also provide a nice escape from work.

2. Location matters. You do not want to be in a place that you think you will be miserable living in. Yes, you will not have a lot of free time in residency, but you want to be able to enjoy the time you do have outside of work. Also, think about quality of life issues. How long will your commute be? How pricey is housing? If you have kids or are planning to do so, how is daycare availability?

3. Be realistic. Every program puts their best foot forward on interview days and at second looks. Even rotating at a program may not give you the whole picture. Realize that every programs has its high points and its flaws. If you talk to enough people you will likely find someone who will complain about something. Try to feel out obvious red flags, ie programs on probation, multiple residents who openly express unhappiness about teaching/mistreatment, programs that do not let you talk to residents at all. Often you don't see any obvious things and this can be good--it can mean that you are considering programs that will all train you well.

4. Match your career goals. This may seem obvious and is more applicable in some fields than others. But I think this discussion sometimes gets lost. Many of us are influenced by our advisers, who are academic physicians, to pursue academic medicine or have only been exposed to academic practices. Also, I've seen that programs often sell themselves by touting fellowship placements since fellowship is the next step in many fields. If you want an academic career, are set on doing a fellowship, or want to do research you should consider these things. However, if you honestly see yourself in private practice as a generalist, this might not matter as much. It is okay to match at a "less prestigious" program if it is the best fit for your goals. When evaluating a program think about where you really see yourself in 5 years, 10 years, 20 years down the road. Then see if the program's placement of graduates will help you get there.

5. Think ahead. It's easy to focus on intern year since it looms ahead, just as it is easy to focus on things like the basic science curriculum when trying to pick a medical school. If you can get some input from upper level residents it can be helpful when evaluating programs. See if they feel supported throughout the program, if they get good career advising, and what they feel their strengths and weaknesses are at the end of the program.

The bottom line is that you will probably have several programs at which you feel you will be reasonably happy at and get good training. In the end, it works out for most people, even if it does not feel that way right now. So take a deep breath and make that final list.

The Lone Coyote Returns

It has been almost seven months to the day since I wrapped up my blog, Medical Student Musings, which explored my experience in medical school. When we last left our heroine, The Lone Coyote, she was adapting to her first rotation in a busy lab and wondering when the heck she was going to have time to study for boards. Since then a lot has changed for the better:

1. I know my way around the hospital and can log into the computer regularly
2. I passed Step 3, so can become an officially licensed physician someday
3. I am more than halfway through this year and eventually will not be the lowest person on the totem pole anymore
4. I am pretty used to getting called and paged and don't feel that sinking feeling in my stomach that plagued me on my earliest call nights
5. Most importantly, I don't look over my shoulder or freeze up on the phone when someone calls me "doctor"

Clearly, I needed some time to adjust to my new life as a resident. But in the interim I really missed writing. Of course, I wrote on a daily basis at work, but it is usually in the form of little bullet points--names, lab values, tests, things to do. I even tried writing about things outside of medicine. Then I realized that I am a resident, so there really is not that much to talk about other than medicine. Even in a "lifestyle-friendly" field, the reality is that work makes up the biggest portion of your day.

So it is time for The Lone Coyote to return to blogging about medicine. If you enjoyed the old blog, I will warn you that this one is going to be a bit different. It is not going to chronicle my day-to-day life in residency. Instead, it is going to be more general in its exploration of issues relating to medical education and health care. We'll see how it evolves, but I can only hope that it will be as fun to write as the last blog was.