Today I started my medical residency. I’ve been out of the clinical setting for months, taking mandatory didactic courses, graduating, taking time off and moving. I was terrified as I walked into the hospital, and that terror only mounted as I worked through the morning.
I was terrified that I’d have forgotten most of what I would need to know to give my patients good care. I was terrified that I’d face heavy criticism from senior residents and attendings for not being able to do things right the first time. I was terrified that I’d offend every nurse, tech, other physician, secretary and case manager I came into contact with, and I was terrified I’d get there and be so out of my element I completely broke down.
None of those things happened.
Photo by: <<saigerow>>
Instead, today felt about like waking up in the morning after my alarm clock went off, getting out of bed and walking around rubbing my not-yet-open eyes, going through the back door and stepping right into a swimming pool.
I got to the floor, sputtered and floundered around for a bit, struggling just to keep my head above the water and nearly panicking. I had four patients I knew nothing about, wasn’t getting return pages from the intern I thought was supposed to have been on last night, was trying to learn my way around this hospital’s EMR to find the admission notes, and possibly progress notes, looking at labs and other data as I went along trying remember what normal lab values should be, and what abnormalities in each value would mean, and what other things would be on my differential for the patient about whom I was thinking, etc. I was struggling so hard to not end up in over my head, that it was hard to slow down and think. It felt like I’d sink right to the bottom if I stopped furiously thrashing about even long enough to try to figure out what I should be doing to swim, instead of just barely treading water.
Then I had a glorious moment while talking to one of my patients and answering questions she put to me. I remembered that I’d done everything I was needing to do before, as a medical student. I remembered something vitally important.
I remembered that I already knew how to swim. I still had to work hard at it, and it still wore me out, but in the end, I did my job and I think I did it well, and now I expect to find myself swimming almost every day.
Freak! A Matter of Perspective
“… so it’s really kind of cool that there are ways we can tell that a person has multiple acid/base disturbances occurring, even if his serum pH is normal. If you look at the basic Chemistry panel you can calculate something called an Anion Gap that helps you know how many…“
“Honey? I love you, I really do, but I just really don’t care. I’m sorry!”
“Oh, that’s… okay, I guess. It’s just really cool.“
This conversation has happened in one form or another between my wife and I more times that I can count. It’s happened at the dinner table, in the car, while getting ready for bed, while lying awake in bed, while getting the kids up and dressed, while doing laundry, while packing our stuff up and getting ready to move.
My wife really does love me, she makes that obvious constantly, it’s just that I’m… well… kind of weird with respect to the things that interest me, at least when placed on the same scale used for your average-everyday-Joe-or-Jane.
It takes an immense nerd to really get into the things I find myself interested in, and I recognize that, but it’s easy to forget when I spend a good chunk of each day surrounded by other people with interests that are similarly outside the societal norms, and often closely related to my own.
That’s kind of the funny part about Medical School: it makes it easy to forget just how unusual our interests and knowledge really are, because we’re surrounded by other “unusual” people.
Recently, the reading I’ve been doing for fun has included a book on interpreting chest radiographs, journal articles about the ethics of confidentiality in cases of community HIV exposure, the details of retroviral-host genome integration, involuntary psychiatric hospitalization, and interpretation of arterial blood gas values and subsequent nomogram production.
And that’s just my medicine-related geekery. I spend so much of my waking time with people that could sit down and talk about this with me and be interested in it, that I forget that once I leave the hospital, most people I’ll run into couldn’t give a fig about any of it.
In the words of the main character in an audiobook I’m currently listening to (John Cleaver, in Mr. Monster by Dan Wells), I’m a freak.
But, then… I’m not.
It’s handy for me to remember this dichotomy, and how easy it is for me to forget (in the right circumstances) that I’m unusual, because I’m about to start a career where, likely every day, I’ll be trying to help someone who doesn’t fully realize how far from the “norm” he is, or who is distressed at being reminded of it.
Commonality of differences between people and the “mean” in any given dimension doesn’t necessarily mean that those differences are unimportant, but that when they are important, it is for more than just the sake of difference. They’re important for how they affect the persons we are and how they affect the way we perceive and respond to life.
This is true for any medical condition, whether physical or psychiatric (or, really, both) as well. Knowing that a person carries a diagnosis of diabetes, or depression, or lung cancer, or schizophrenia doesn’t by itself give me any useful information about him. It’s how those diagnoses affect his life that is important.
I think, sometimes, doctors (something I will soon be) forget to think of our whole patients in our drive to know, understand, and treat diseases.
On Health Care “Reform”
I’ve followed health care reform since it started getting a lot of attention from Pres. Obama at the beginning of his presidency, particularly closely since May of 2009, when I made a trip to Washington, D.C. to lobby with the ACP for what I felt to be the most necessary changes to the failings of our current health care systems.
I’ve read the text of the bills as much as possible every time a new bill rose to the forefront, though it became more and more difficult as the length grew and grew. Every time the health care bill went through compromise and revision, what I felt to be important parts were pulled out and replaced with things that I don’t think address the real problems of healthcare, until there isn’t much of the initially quite promising legislation left. Some of those things I believe will contribute to making some things worse.
I’m ambivalent at best about what has finally passed. Some important regulations were placed on the out-of-control private health insurance companies, but some very suspicious (at best) concessions were made as well. Pharmaceutical companies seem to have escaped unreformed, and while health insurance companies lost some ground to regulation, they gained what may be significantly more ground from requirements for almost all citizens to carry health insurance.
Medical student indebtedness is one of the major obstacles to students choosing to pursue careers in primary care, because it simply isn’t well compensated compared to the rest of the field, and $250,000 of debt (on average, a few years ago) is a staggering amount of debt for anyone to be staring at as he graduates from school, particularly considering that he may be making less per month than the monthly interest accruing on his loans. If we’re to address the shortage of primary care physicians in this country (and we need to if we are to truly reform health care) we need to address those things that are seen by graduating medical students as barriers to pursuing careers in primary care. This legislation starts to address that, but I’m not sure it does enough, and I’m not sure everything it does will help.
All that said, we still have, in this country far more freedom than in Cuba, or China. We still have far more protection of our basic human rights. We are still far, far, far from the abuses of those countries, and I’m very, very tired of the misplaced comparisons to them. And even if we were moving closer to such countries in a significant or meaningful way, which I don’t believe we are, there is good to be found in them, as well. Despite the things we may disapprove of in such governments, I don’t believe it is possible for everything about the countries to be “bad”, and thus becoming more like them in one aspect or another is not innately bad. The determiner of good or bad must, then, be the change that is made itself, and not who it may or may not bring us closer to resembling.
Considering the cruft that made it into this bill, and the important bits that were removed, you won’t find me celebrating much tonight. But you won’t find me lamenting the destruction of our freedom, either, because that freedom still thrives, and is (on the whole) in no immediate danger from this bill.
Instead, you’ll find me looking at this as a first step. One that isn’t in the direction I’d like it to be, but a first step nonetheless, and an opportunity to use the momentum it might create to propel us, with the aid of future legislation to refine our course, to redirect us toward everyone in our country having access to basic health care. Not necessarily receiving “free” health care, but having access to basic healthcare at a cost they actually have the ability to pay.
I firmly believe access to basic healthcare is necessary for the practice of the most basic of human rights, those considered to be so basic and inalienable that their violation by the government at the time was listed as the impetus for what has become the United States of America in declaring independence from Britain: Life, Liberty and the Pursuit of Happiness.
You’ll find me hoping what I’ve experienced to be true in so many other aspects of my life holds true here: that it is far easier to change the direction that something is moving than it is to get it moving in the first place.
So, here’s to continued change. And I think this is something that even those of you who cannot find anything redeeming about this legislation can agree with me on: now is not the time to stop pursuing what you feel is right, but rather now is a time more important than any time we’ve ever seen to work to exert our influence in directing the change that has begun toward the ends we feel will be best for our country, and for our fellow citizens.
I hope to see many of your out there, and even if you’re pushing from the other side of one or more of these issues, even if you’re pushing directly against me, I congratulate you for pushing, and hope that perhaps as we steer this thing along its path, we’ll end up pushing side-by-side at some point.
What we cannot do any more is try to keep this change from happening, because it has started.
Change, is now.
Pfff.
That’s the sound of me fizzling. I’ve missed a number of days posting on the blog, meaning I definitely can’t call this NaBloPoMo a success, and I’m severely behind in my writing, such that I’m not going to make the 50,000 words for NaNoWriMo.
But you know what? I’ve been having fun, so Pfff is also the sound of me scoffing at my own expectations.
I’ve mostly been having fun.
Except for the part about my kids coming down with what looks like H1N1 (or, as my sister calls it, the Hiney).
That hasn’t been so much fun but hey, it’ll be a week or so and then the not-so-much-fun will pass. Then I just have to hope the kids start sleeping normally again.
Oh, the power of cheese.
So, I’m in my third year of medical school now, and rotating through different services in the hospitals. Each rotation ends with a mandatory exam, usually a nationally standardized exam we call the “shelf”. The most common comment I’ve heard or read about shelf exams is, “it was a pretty hard test.” Needless to say, there’s usually a fair amount of stressing about these exams, and I don’t know anyone who would say they enjoyed any part of the studying for them, because it just feels so hectic.
Until now.
An amusing question from one of the practice exams I did preparing for my Psychiatry shelf exam today:
A 24-year-old man presents to the ED with symptoms of PCP intoxication and a positive urine toxicology screen. What is the best treatment for extreme agitation in this patient?
- Trihexphenidyl
- Bupropion
- A phenothiazine antipsychotic
- A Butyrophenone antipsychotic
- Fluoxetine
If this patient is not experiencing extreme agitation, what is the best treatment?
- Vitamin B12
- Supportive care
- Vitamin E
- Lorazepam
- cheese
(emphasis mine)
It’s a very, very good thing that question was on a practice exam, and not the shelf today, because as it stands, only my wife had to experience the laughing meltdown as I lost it after reading that question. Had it been on the shelf, I’m quite certain I’d have been removed from the room.
Now, cheese does get discussed when talking about pharmacotherapy for psychiatric issues, because it can cause adverse effects when eaten by patients taking a specific class of antidepressants, but I can’t recall ever having actually heard or read it discussed as a therapy unto itself.
Who knows. Maybe we’re missing out. The American Dairy Association certainly thinks there’s something there.
I, however, am going to go to bed tonight, still laughing at the thought of treating PCP withdrawal with cheese.
