One down, eleven to go

Well that wasn't so bad. The first month of intern year only took about 31 days and I managed to survive all of them.

It turns out, though, that the ENT service at this particular hospital is wholly unlike any ENT service I've seen before. This service is dominated by one particularly prolific, fantastically mustachioed, head and neck surgeon. This man has assembled a unique team comprising other attending head and neck surgeons, an oral maxillofacial surgeon, a head and neck surgery fellow, a PA, an NP, and a gaggle of residents. Together, the team facilitates a near continuous flow of complex facial reconstruction patients through the operating room, to the surgical intensive care unit, to a dedicated head and neck step-down unit, to a standard hospital room, and, finally, back home good as new. Well, sort of like new, except with various distant body parts now SURGICALLY ATTACHED TO THEIR FACE.

Sure, there were plenty of standard cases - thyroids that had to go and necks plundered of lymph nodes that might be hiding cancer cells - but this finely-tuned machine churned out some cases that I might not have seen anywhere else. At one time, I was taking care of three people whose jaw bones had been consumed by cancer. Large segments of the jaw bone had been removed then rebuilt using A BONE FROM THEIR LEG. Crazy, no? How about the guy who's esophagus was taken out and rebuilt using a rolled up tube of abdominal muscle and it's overlying skin? The radiologists puzzled over an image from one of his studies for hours before finally diagnosing "hairy esophagus."

While last month was unquestionably rewarding, it was not without it's sacrifices. I'd leave the house at 5:30 AM and return between 9 and 10 PM, so I would go many days without seeing my daughter awake. I'd be home just long enough to try to eat something, tell my wife how much I love and miss her, then go right to sleep. And I've come to learn that sleeping 5-6 hours a night (to say nothing of the on-call nights) just doesn't cut it for me. One afternoon during my second week on service, I realized that I'd been so exhausted that I'd written the wrong date on all of my notes that morning. It was July 9th, and I'd been writing July 8th. A mistake made more painful by the realization minutes later that July 9th was my birthday.

How lame is THAT?

So, I think the take-away message is that this year will be a HUGE hassle. But I'll learn plenty. In just 31 days I've already learned to radiologically differentiate candidiasis from hairy esophagus; I've learned that you have to turn the knob left then right in order to open the staff bathroom on the tenth floor of the hospital; I've learned to eat and drink whenever the opportunity presents itself whether or not I'm hungry or thirsty; and I've learned to double check the calendar in the morning to be sure that my notes are correct and to ensure that I collect on any presents that might be coming my way that day.

An update

I finished medical school. I've started my residency in "otorhinorlaryngology - head and neck surgery." I put that in quotations because I don't want you at any point prior to the second quotation mark to think that I've stopped telling you the name of my specialty. Of course, I'll rarely use all those words to describe my job. Surgeons like to abbreviate everything (the substantive part of the last note I wrote in a patient's chart read: pt in NAD. Flap viable BRBPP), and nobody knows what an otorhinolaryngologist hyphen head and neck surgeon is anyway. So most folks are just "ENTs" or "ear, nose, and throat" surgeons.

For now, though, I long for the problem of trying to pronounce my job title. I'll have no such difficulty this year. This year, I'm "the intern." When I'm introduced to the team, I'm "the intern." Instructions are given to "the intern." Pages are returned by "the intern." Supplies are carried in the bulging pockets of "the intern." And, most importantly, any mistake made by any team member that can plausibly be attributed to someone else, were made by "the intern."

For this month, at least, I'm the intern on the ENT service. So the team goes pretty easy on me. Sure, my scrub pants sag under the weight of 3 constantly buzzing and beeping pagers, and my pockets are swollen with the entire contents of any given hospital supply closet, but the residents have some vested interest in seeing me learn how to manage patients competently. I'm told that the experience of being an intern is very different on, say, the vascular surgery service which is run by general surgery residents. The vascular guys will never work with me after my month on their service. In that setting, the senior residents benefit only from running the intern into the ground, getting the most work out of him before he leaves for some other team. This is to say nothing of the NATURE of the work on the vascular surgery service. I won't go into too much detail, but you can probably imagine the sights and smells associated with the skin of a diabetic foot that doesn't have enough blood getting to it.

Would you want to change that bandage and examine the festering foot hole underneath a dozen times a day? Neither would I. Let's call the intern.

Some of the things I don't know

This week we began our "Physical Diagnosis" sessions. This is when they'll teach me to do all of the things that doctors on tv do: listen to stuff with a stethoscope, grope people's internal organs (though we've already been told to use the verb "palpate" when talking to patients), tap on a belly with my fingers, rub up against some lymph nodes. You know, doctor stuff.

So when the day came for my first session, I packed up my bags, grabbed my passport, and joined three of my classmates for a journey over the East River and across the border into Brooklyn. When we arrived at our designated hospital, we met up with Dr. F who herded us into a conference room and began to outline the physical exam on a white board. Now, we've had virtually no meaningful instruction regarding the physical exam, so this brief outline - which contained little more information than can be discerned by an attentive bout with Hasbro's "Operation" - was riveting. But I didn't want to just hear about spleen groping, I wanted to watch it up close. So when Dr. F announced that we were going to hit the wards to meet some patients, I leaped from my chair. I'll get to watch Dr. F listen to stuff! And palpate stuff! Just like they do on tv! And when she finds a patient with an upside-down spleen, Dr. F will turn to us and say, "Now Medical Students, come palpate this upside-down spleen." Then we'll all shuffle over to the bedside to fondle that spleen while we solemnly nod to one another and mutter things like, "that's assuredly upside-down."

So out we walked into the corridors of the hospital, imagining all of the great anatomical oddities that Dr. F would reveal to us. But when we stopped at a patient's room, Dr. F looked at me and one of my classmates and told us, and I paraphrase here, "to go on in there and get us a physical exam." Then she turned around with the other students and left.

"Shit. Do you remember where the liver is?"

So my partner and I walked into the room and found Mr. S sitting on his bedside. He was a thin man with neatly trimmed hair and a quick smile. He was delicately folding his clothes and placing them in a drawer at his bedside. Mr. S was more than happy to discuss his case with us, and generously allowed us to examine him. Unfortunately, neither of us were familiar enough with the physical exam to really learn much from that component of the visit. However, we were both well-versed in taking a good history, and the story Mr. S had to tell was certainly a memorable one. It goes something (but not exactly) like this:

Mr. S had been diagnosed with diabetes decades ago, but he wasn't all that good about taking his medication. He tells us that he always felt alright, so he didn't think it was necessary to pop all those pills. After failing to control his condition for about 20 years, his peripheral nerves and blood vessels started falling apart, and doctors were forced to amputate his foot. Now, some years later, Mr. S is back. He hasn't been taking his medication, and he's had his second foot amputated.

Mr. S had worked as a paper pusher in an office before his first surgery, and had been put on disability shortly thereafter. I never asked whether he had been insured during those first 20 years, so I don't know whether his personal finances played a role in whether or not he took his medicine before he lost his first foot. However, he has been eligible for Medicaid since his first surgery, and the pattern hadn't changed. In fact, he continued to smoke two packs of cigarettes each day.

Recently, we've had a series of lectures on the economics of health care. One of the lectures was delivered by the President and COO of GHI in New York, Dr. Aran Ron, MD, MPH, MBA. GHI has recently merged with HIP to become the largest health insurer in New York. At one point in his presentation, Dr. Ron referenced studies that illustrated one of the problems that insurance companies - and the health care system at large - are confronting. When a patient with insurance walks into a hospital, they have no reason whatsoever to curtail spending. I can imagine that if I were lying in an emergency room with an excruciating pain in my back and a doctor says to me, "I'm 99.9% sure you've got a kidney stone. I've seen thousands of these things and you've got all the classic signs. But you MIGHT have something else. The only way I can know for sure is to order a very expensive CT scan for which you will pay precisely nothing." At that moment, I would be gasping incredulously while trying to muster the strength to punch the guy in the nuts for wasting all of that time talking to me when he could be wheeling me to his very expensive scanning machine.

Dr. Ron's claims were echoed during another lecture by Dr. Sheri Glied, Ph.D., who is the Chair of the Division of Health Policy & Management at Columbia's Mailman School of Public Health. Just to avoid anyone misinterpreting the reason for me writing about this, Dr. Ron, Dr. Glied, and I are all proponents of universal health care (though Dr. Ron can't have the GHI higher-ups finding out about this, so please, Mom, Dad, and Dan, don't tell Dr. Ron's bosses). Much of our health economics lectures centered around elucidating the profound challenges involved in implementing universal health care in America - not just politically, but in terms of controlling costs and ensuring high quality care.

During Dr. Glied's lecture, she referenced other studies that claim to show, not surprisingly, that people who are insured visit the doctor more often than those who aren't insured. Consequently, she said, if the 47 million uninsured Americans suddenly became insured, our health care system wouldn't be able to handle the surge in demand. This argument didn't sit well with some of my classmates, one of whom became particularly vocal. This student believed that it was absurd to believe that anyone would go to the doctor for any reason other than that he or she was sick. Nobody would take time out of their day - often several hours - to go sit in a waiting room if they didn't think they really needed it.

A medical curriculum is based primarily on repetition. We hear the same stuff over and over again to be sure that we remember it when it matters. And one of the things that I've learned over and over again is this: "there are lots of people who show up in hospital beds who don't think about the world the way I do." I agree with my classmate that it would be absurd to take three or four hours out of my day to see a doctor for a headache when I could much more easily wash an aspirin down with a cup of coffee. But I fully believe that there are plenty of people who would be lining up outside the MRI scan to rule out brain cancer before returning to work.

And what can be done about patients like Mr. S? Is there any way to put the onus on him to take care of himself? It's one thing to spare no expense to keep someone healthy, but is there any alternative to keeping someone alive while he fastidiously tears himself apart?

When closets risper

In my seventh grade french class, my teacher would try to come up with the most absurd mnemonics to help us remember french vocabulary. For the most part, it worked. To teach us the word for "lobster," she suggested imagining coming home from school one day to find that your mother had been turned into a giant lobster madly flailing around on the floor. You would almost certainly yell, "oh, Ma!" Which is the way the french pronouce "homard" (because the french pronounce things incorrectly).

I've been doing very little learning over the past year. Primarily, I've been memorizing. So it's no surprise that I've come across my fair share of mnemonics. What is surprising is how truly awful these mnemonics are (with the exception of the very memorable, sexually-explicit ones which I won't be sharing on this site). For instance, to teach us that the deep cerebellar nuclei, from lateral to medial, are the dentate, emboliform, globose, and fastigial, our textbook suggests, just remember DEGF!

It sometimes even seems like these text books prefer the useless mnemonics to the memorable ones. All of our books and lectures constantly refers to "SIG E CAPS" as a way to remember the diagnostic criteria for depression. Those are:

1. Sleep disturbances
2. Loss of interest
3. Guilt or feelings of worthlessness
4. Loss of energy
5. Loss of concentration
6. Change in appetite or weight
7. Psychomotor retardation or agitation
8. Suicidal ideation
9. Depressed mood

Notice that #9 doesn't even play into the SIG E CAPS criteria for depression.

A much more accessible mnemonic is "Depression is worth studiously memorizing extremely greuling criteria. Sorry." Which correlates with: depressed mood, interest, weight, sleep, motor activity, energy, guilt, concentration, suicide. I've only read this mnemonic once in any text.

Today, I was studyig the atypical antipsychotics (the first generation of these antipsychotics are now called the "conventional antipsychotics", and the most recent iteration of these drugs is called - I kid you not - the "atypical atypical antipsychotics"). Three of the more important atypicals are clozapine, olanzapine, and risperidone, and next to a list of these drugs in my review book is the mnemonic "It's not atypical for old closets to RISPER."

That's right. Normally closets risper. Specifically when their old. Don't forget!

In the opening weeks of this year our course directors overwhelmed us with labels for parts of the brain and told us to memorize them. To our untrained eye, none of these parts looked any different than any other parts. The brain's just a big ball of wrinkly mush, and we were expected to remember the names of the wrinkles. In an email to the class, one of my classmates wrote "I always had a tough time remembering where the calcarine sulcus was until I realized it was right between the cuneus and the lingual gyrus." I thought the sentiment was funny enough to repeat to other people, and now, ironically, I never forget where to find those three parts of the brain.

So here's my new plan. I'm looking for the most nonsensical, useless mnemonics to compile into a list that I can routinely look over and make fun of. As these nonsensical strings of letters vie for the title of the most useless string of letters, hopefully, in the end I'll at be able to remember the battle and, by extension, the relevant medical knowledge.

New year, new body parts, new patients

The last time I posted, I was just a first year medical student, naive to the ways of the world and ignorant of the practice of medicine. Much has changed since that last post. Specifically, two things have changed. First of all, I'm now a second year medical student which means I'm allowed to shove first years into their microscope lockers or slip cholera bacteria into their drinks in the cafeteria. The second change is that I've almost completed our Brain and Mind course. So, while I'm still entirely ignorant of the practice of medicine, I'm only largely ignorant of the way a healthy head is supposed to work.

Last year, most of my patient contact was with patients from a small general practice. These folks were typically getting checked up to make sure their diabetes or hypertension was under control. Later in the year, I hung out at the lymphoma clinic at the cancer hospital next door. While lymphoma can be a serious and life-changing diagnosis, the patients I worked with weren't acutely ill. More often than not, I would spend my time chatting with them about their medical, social, and family history then watch the doctor glance over a few charts and say something along the lines of, "I see no reason to begin treatment now. How about you come back in six months?"

Over the course of the year, I became very comfortable taking a patient history, so I didn't think much would change this year when we started interviewing our psych patients. It's just an interview, right? I ask questions, write down answers, smile when it's appropriate, frown when they frown. Piece of cake, right?

So there are a couple of reasons why my interviews with psych patients have been difficult. The first is that some of my patients have had fairly profound cognitive deficits. Before my first interview, I had assumed that the course administrators would start me off slowly. Maybe a patient with a mild mood disorder that's in remission. Maybe someone with hypomania and I'll diligently write down that "the guy talks fast." But, no. My first interview with a psychiatric patient in a clinical setting was with a schizophrenic patient with a string of suicide attempts on her record. The interview was not much like the medical histories I'd taken before (and, of course, the details I'm about to provide are changed from the patient's actual story, but the gist is there). The patient, who was bandaged up pretty well and confined to a wheelchair, told me that she was brought to the hospital after she fell off a subway platform and was hit by a train. Her expression didn't change, but I frowned anyway. It seemed like the right thing to do.

"So, can you tell me what happened before you fell off of the platform?"

"I needed to get away. I needed to get away to join the army, but I couldn't get on the train because I'd get caught and taken back to the hospital, so I jumped into the tunnel."

You know what's not an appropriate follow-up question in a medical interview? You're about to find out.

"Seriously?"

I was rarely able to elicit both a relevant and decipherable answer from this patient. The rest of the interview involved tangential and nonsensical discussions of whatever she wanted to talk about.

The second reason that I've found these interviews so difficult is because the information is so unreliable. This isn't because psychiatric patients are unreliable (though, obviously, there are some conditions that impair cognitive function to a degree that the history you get is clearly untrue). Rather, the information is unreliable because the interviews focus on the one subject that elicits the most guilt or embarrassment from the patient. If I spent forty minutes talking to a hypertensive patient about his salt and cholesterol intake ("Oh doc, I've been eating real good. Last night I had this, like cauliflower gratin with capers, it was DEE-lectable!"), I guarantee you that the meals he describes would all come from Weight Watchers commercials he watched while eating potato chips and licking sticks of butter.

Psychiatric patients often know exactly what would concern their doctor, and if they're not concerned about it, their doctor's not going to hear about it. Often, it's not until I get back to the nurses station and read reports from other clinicians or family members that my questions get answered. Like all those questions I had about the kindly, older woman who thinks I have "just the most beautiful smile!", who houses stray dogs, and who told me that she never drinks and didn't even touch alcohol until she was 28. It turns out that woman has about a half dozen drinks a night to wash down her benzodiazepines.

Accordingly, most of our patients don't think they have anything to discuss, but they'll chat with me to help me complete my school assignment. And at the end of the interview, I have to determine exactly what it is that the patient is most worried about. That thing, their chief complaint, is listed first our reports. Last year my reports started like this:

CC: Patient has had a productive cough lasting two weeks

or

CC: Patient is experiencing acute lower right quadrant abdominal pain

This year the chief complaints look different. Like this one for the homeless, alcoholic who believes the CIA is watching him from cameras in traffic lights:

CC: "The nurses won't give me a second cup of apple sauce."

Or from the woman addicted to an enormous list of prescription drugs:

CC: The doctors here are too young, and "lack the sophistication to understand me."

I graduated college with a double major in english and psychology. By the time I completed my psychology coursework, I had become one hundred percent certain that I didn't want to pursue it as a career. But many of my closest friends and family members have been treated by a psychologist or a psychiatrist, and I've always been aware of the profound impact a psychiatric disorder can have on a person's life. The science behind psychiatry is only now starting to catch up with the theoretical component of the profession. For that reason, I've heard lots of doctors and future doctors scoff at psychiatry, saying that it's make-believe, not a science. But over these last 10 weeks, I've found it hard to imagine a more important area of study.

Schizophrenia affects more than 1% of the adult population, a figure that I find absolutely staggering. Now I understand that, unless schizophrenia drives you to suicide (and teens with schizophrenia have approximately a 50% risk of attempted suicide), you're not going to die from a psychiatric disorder. But I suspect that if you had to wake up tomorrow morning with schizophrenia, an unremitting major depressive disorder, or lung cancer, you probably wouldn't mind rolling the dice with surgery and some chemotherapy. For precisely that reason, I believe we need our best minds researching treatments for psychiatric conditions.

Fortunately, mine is just a mediocre mind, so I can do whatever I want.

The Scholar Athlete

Sometime in the early spring, one of my classmates was inspired to start a dodgeball league for our class. He sunk hundreds of dollars and an unseemly amount of time into running this league in the gym underneath the school's dorms. As ridiculous as it may sound, by the time the first whistle was blown, our league had eight teams of 7-10 people each. In a class of a hundred neurotic science geeks, that's not so bad.

Slowly over the course of the spring, I began to realize exactly why the neurotic science geeks flocked to the dodgeball courts. As it turns out, the students in my class are some of the most wildly competitive people I've ever seen. The idea of beating someone else at something - anything - is like heroin to these folks.

It should be noted here that I am purposefully not including myself in this description. I've been working fastidiously for the last four years - since The Monopoly Incident - to prove to the fiancee that I can be trusted to control my competitive instincts during playtime. For the purposes of this post and for the sake of my upcoming marriage, let's say that my behavior on the court never wavered from that of a good-natured sportsman.

The games varied pretty widely from a rollicking good time to endlessly frustrating. Even while watching other teams play from the sidelines, I would see the same guys get hit, sometimes three times in one game, without ever leaving the floor. Competition's one thing, but doesn't the face-rubbing lose a little bit of its joy when you're the only one on the court who believes you won?

You wouldn't guess it from the victory dances.

In some ways, the unbridled competition was impressive. Even inspiring. One of my classmates, K, absolutely sucked at throwing the dodgeball. It's clear that, though K keeps himself in good shape, he did not grow up playing baseball. Actually, it's unlikely he threw anything at all, though even that couldn't explain the motion of K's arm when he throws a ball. I imagine that K probably grew up with his elbows sewn to his nipples. Nonetheless, he seemed to spend hours each day down in the gym working out with the dodgeball. His progress was remarkable. By the end of the season, K was one of the better players on his team. He threw reasonably well and nobody could get him out. No matter how many times they hit him with a dodgeball.

Who doesn't love a pygmy marmoset?

In between the last post and this one, I had a course in Host Defenses. It was a nice course, but generally unremarkable. Except that now, on top of all of the other specialties that I've been certain I'll make a career out of, I've added infectious disease to the list. Do you think they'll let me be an emergency orthopedic neonatologist that specializes in infectious disease?

They would if I worked at Seattle Grace.

So first year is done with, and I've started an eight week research fellowship at the Hospital For Special Surgery. The goals for this summer are two-fold. First, I need to get some research experience under my belt. Strangely, my teaching resume is pretty sparse when it comes to basic science or clinical investigation. Second, I would LOVE to rule out surgery as a future profession. Getting into surgical residencies can be pretty cutthroat... and if I could avoid that, it'd be nice. My hopes that orthopedic surgery will be profoundly unfun spring primarily from two sources.

Source A: I've said it before, and I'll say it again, cutting people open is gross. I remember when I studied abroad in Scotland, I used to walk into their fry shops (shops in which they fry things), and ask them to drop a Mars bar into their frier for me. I can't accurately describe the taste of this beautiful, deep fried, golden brown confection. But I remember that when I bit down on it, I'd pierce its thin, tough fried skin, and out would ooze this melted, gooey, chocolate center. After my first experience watching surgery, I don't think I can eat a deep fried Mars bar ever again. I have a new rule: If something's got skin, the skin should stay on.

Source B: Rumor has it that orthopedic surgeons are misogynistic, weight-lifting, ass-slapping, scalpel jockeys. I did notice that some of the young, male orthopedic attendings who dropped in on our anatomy labs used to spend inordinate amounts of time at the tables of the more attractive female med students. But I have a cousin who's an orthopedic surgeon, and he's not one of those guys, so the jury's still out.

So far this summer, the surgeons and staff that I've met at HSS have been terrific. Funny, down to earth, with just the right amount of ass-slapping.

This week, I've been going to the residents' lectures. It's nice, because I get to get up before 6 am and go sit in a lecture hall and watch powerpoint slides. This morning, as the lecturing pathologist was poring over slide after slide of unhealthy bone, he turned to a slide that looked much like this inset picture. He summarized by saying in the droning monotone he'd used since slide 1, "so if you notice anything in a histological section that shouldn't be there, well, it's probably pathological. Like this, for instance."

Pause, no reaction from the residents.

"This baby, pygmy marmoset does not belong on anyone's finger."

Pause, no reaction.

"It belongs on your stethoscope"

...

"In the pediatric wards."

Still nothing.

"They are a... they're a hit."

So, now I'll have to add pathology to the list. Those guys are a riot.