And So I Enter the Surgi-Cell

Is it odd to dread the thing you love?

For the past month, I've been biding my time on Pediatrics, watching the surgery team burst onto the floor, parade around importantly, impatiently jiggle a few bellies and pack a few abscesses and disappear. Every intern I spoke with had the attitude of "Good luck, dude...", with a head-shaking and low whistle. I've been alternating between envy and fear.

And on Sunday, I started.

As is my luck, I caught a bug from the NASTY GRUBBY IRRITATINGLY ADORABLE MONSTERS of pediatric clinic on the second to last day of the rotation. I couldn't really complain, since I constantly have colds and I was very much overdue for one, but I really did try the entire rotation to keep myself clean. I was doing ok on Saturday, coughing a bit but handling things well on some vitamins and Tylenol. But by Sunday morning, I was a raging mess, and never really had a voice to lose in the first place.

As is also my luck, it wasn't a bad call work-wise. Sundays are typically used for cleaning up the surgical patient list, cleaning up messes left over from Friday and Saturday, and just generally keeping things under control. I lucked out with a senior resident who was understanding of my not being too put-together on my first day, and a medical student who was experienced enough that I didn't have to stay on top of her work. The list wasn't too bad, there were no massive emergencies or codes, and no cases.

However, I spent the entire day sweating up a storm, coughing my brains out, swallowing thick snot, sneezing (that deep, worrisome kind), and generally feeling fatigued and not myself. I caught myself at several points throughout the day, gazing off into space and forgetting which task I was meant to be taking care of. I didn't drink enough water, and forgot to take my vitamins and Tylenol. I wasted a lot of time that could have been used towards getting my notes written and following up on labs, and as a result only got about 2 hours of sleep. I forgot a patient on the list who was still sitting in the ER, and had to frantically write my note at the last minute. I found myself oddly energetic at points, though, as if my cold was breaking, and my adrenal glands had gotten the "Go, team, GO!" message and kicked into gear. By the time I got to morning rounds, I was so wide awake that my worst reaction to a hoop-jumping request from my chief resident was just mild grumbling. I popped 2 Benadryls while pulling out of the parking lot at 10 am, and fell asleep pretty quickly, planning to sleep away the day and not worry about studying. Paradoxically, letting myself sleep away the day guilt-free meant that I was feeling much better when I woke up, and was actually able to study for a bit.

My day today, while hectic, was actually pretty good. I stayed quiet most of the day so that I could learn how things were run, and got assigned to help with a few minor procedures because I was the only intern on surgery who was a surgical intern. (My first ever fecal disimpaction was a bit of a letdown, because I didn't get the big rush of poop coming out that I was hoping for. C'est la vie.) I stayed to help out the intern on call, and by the end of the day, I actually felt like I had a feel for how things worked, and I went home happy.

My call was awful, and I was terrified for today, but I survived. It wasn't that bad in the end, and I realized that when push comes to shove, I am tougher than I give myself credit for. I'm not incapable, just inexperienced, and luckily I have five years to resolve that. I can do it. I am happy and empowered =)

My Teachers From Near and Far

I've just finished week 3 of pediatrics, and I must say that I am enjoying it a lot more than I expected. Our attending, Dr. J, is just fantastic. When I came into the rotation, the outbound medical students warned me that he was a person to be feared on his "bad days", and often was short with them, etc. On my first day of the rotation, he sharply rapped his hand on the cart of patient charts when his student yet again failed to present the patient's clinical progress and physical exam in the correct progression. Rounds with him are tough, because he expects us all to be thorough with our patient interviews and exams, but you always come out of it feeling as though you have learned more. In my weeks with him, he has been not only professional, but extraordinarily kind and gentle with his patients and their families. It always seems as though he has seen everything, almost as if he can divine diagnoses. He knows exactly what's going on with each patient, and which are good cases to see, and which complications should be anticipated. Furthermore, it's effortless for him to spout key information while guiding everyone into doing the work exactly as he wants it done.

Notably, Dr. J is foreign-born and trained. He speaks with a strong accent, has a difficult to pronounce name, and can be unorthodox in his manner of interaction with people. He is not alone in these features - I have had many foreign-born attending physicians who were brilliant, unparalleled in their clinical skills and breadth of knowledge base, but perhaps also have certain features that could make any patient who isn't "in the know" be wary.

Pauline Chen wrote a piece this week on this same issue, discussing the unfortunate nature of this situation. In the United States, there are typically more residency spots per year than there are American graduates to fill them. Usually, those spots will either go empty, or are filled by graduates from foreign medical schools. These graduates, for lack of a better categorization, are typically Americans who attended school abroad (most often in the Caribbean), or foreign-born doctors who attended school in other parts of the world (India, China, Europe, Africa, Central and South America). The second group, simply by originating from countries where academic competition is far more rigorous than in the US, tend to be the cream of the crop for those nations intellectually, and score better on medical exams than even our own medical students and residents do. Having trained abroad, they often have seen a far greater volume of cases than we get to, and are drilled much more heavily on traditional subjects like physiology and pathophysiology than we are. Also, since they may not have had as immediate access to imaging and laboratory studies as we do, their clinical diagnostic skills are often superior. They represent a unique opportunity for American medical students and residents to learn, because we may go our whole residency never seeing a real case of measles or malaria, and those classically tested subjects were most likely bread and butter to them on clinical rotations.

However, I have certainly seen more than a few foreign-trained doctors with a total lack of understanding for the culturally and socially specific needs of the American patient. On my first day of 3rd year internal medicine, there were several new residents in the program who had no earthly idea of which illegal drugs had which commonly used nicknames, and what the various routes of administration were. Nor did they care to ask, because they were too focused on the more immediate, tangible medical issues at hand. I later rotated with an Indian-run suburban family practice group that almost never suggested Gardasil for their pre-teen female patients, and barely discussed it even if prompted. Their reasoning was that good Indian girls don't have sex when they go to college, and it wasn't a conversation that needed to be had, even if just to ensure that those girls didn't become sexually active. (Having attended an American college in a large city, I can emphatically state that Indian girls DO IN FACT have sex in high school and college, they just don't tell their parents.) Discussions regarding psychosocial issues behind dangerous behavior patterns nearly never take place, even while the pediatric and obstetric-gynecologic communities are pushing for increased openness. But again, this is no hard and fast rule - Dr. J and several others I have met all fully investigate these issues, and are sometimes even more skilled than the average psychiatrist in teasing them out.

Pauline Chen brings up one more objective method of evaluating a doctor's abilities, better than the name of the med school a doctor graduated from, or where he or she did her residency, or what the scores were on all the exams. She points to the board certification, which is the designation of a physician who has demonstrated mastery in his or her specialty, as deemed by the Board of that specialty. Usually this involves a written exam, and often an oral exam as well. It is a rigorous process which is completed after completion of residency and/or fellowship training, and re-certification has to be done every 7 to 10 years (depending on the field). It is a super expensive exam to take, and if you're the only doctor for miles, it doesn't have much value because people will come to you anyways. So while not being board-certified doesn't indicate lack of competence, having it does allow some degree of assurance of knowledge and skill in the specialty.

The problem with board certification is that virtually nobody in the general population even knows what the heck it is. Even amongst people who have some connection to the medical world, like family that has seen you through the process or people working in the field, it is very easy to confuse the MCATs (med school admission test), the Step 1 Boards (at the end of 2nd year of med school, testing book knowledge), the Shelf Exams (following each 3rd year core clinical rotation), the Step 2 Boards (during 4th year of med school, testing book and clinical knowledge), the Step 3 Boards (during first 2 years of residency, testing clinical knowledge), the in-service exams (yearly testing during residency, for your specific specialty) and the Board Certification exam. Oh, and state licensing, which is when you register with your state as a physician and they license you to practice, and you can now write prescriptions without having another doctor co-sign with you. When a friend seeking a primary doc decided he wanted a board-certified internist, he still had no idea of how to search for such people in his area, and then figure out if they took his insurance or not.

So, I suppose the point of all of this is just to say that there is no 1-click way of knowing which doctors are competent for your needs. Do you research to narrow it down to a few people that fit your needs, then try each person out. Sometimes, it's hit or miss. But the foreign-trained physician gems are there, and far more of them exist than we give credit for.

To Sir, With Love

One aspect of medicine which is so pervasive, yet infrequently discussed, is the role of teaching. By this, I mean the day to day, person to person teaching that happens on every rotation that one goes through as a student or resident. I've always enjoyed this part, because it makes me feel like learning is a tangible discussion, rather than a formal and stiff lesson. There's something thrilling about walking away from a lively spontaneous discussion on sickle cell anemia or primary amenorrhea, that makes you feel like you gained so much just by staying tuned in for an extra five minutes.

What's not so easy, I'm discovering, is leading that teaching process. I've always loved sharing information with others, and reinforcing what I think I know with a group of people who inevitably remember better than I do. As medical students, we are continuously expected to teach and help each other, as well as to give more formal talks on disease processes and case presentation. But I'm realizing now that this type of teaching, which is simply informational, is the easy part. What's not so easy is to teach someone how to be a medical student, how to get through doing physical exams and admissions and learning to formally present a patient at rounds. I remember helping third year students with this last year, and I never found it as difficult, perhaps because the responsibility ultimately didn't fall with me.

But perhaps I was also lucky, and didn't have too many encounters with that Thorn In Your Side, the lazy medical student. Most medical students I knew, often my friends, were incredibly smart but also terribly hard working. They didn't mind coming a little earlier or staying a little late to get things done, especially if it meant learning how to do something new that would later be an expected responsibility, like drawing blood or placing IV lines. I myself enjoyed staying late to learn how to do central lines or surgery consults, because I wanted to be sure that I at least had an idea of how they were done before I was expected to do them regularly. This is, of course, most likely a ridiculously rosy picture of myself, and I know that on many occasions I have been an inadequate or incompetent student. But I can say with 100% certainty that I always tried hard.

Somehow, it never occurred to me that there are some people who make it past the first two years of school and are still trying to make it through with as little work as humanly possible. These are the people who don't want to see the complicated cases, even if they are classically tested on the board exams. These are the people who don't want to learn how to properly present a case, and refuse to recognize the value in an efficient exchange of patient information between colleagues. These are the people who consistently disappear to the cafeteria or library if you don't keep your eyes on them, and always have a complaint about something or another. Every conversation is about which specialty gets you the most money for the least work, and every assignment is met with a complaint (and even talking-back). And, of course, these are the people who are most persistent in asking about how to game the system and get the best recommendation letters.

A lot of residents I know are of the mentality that if a person wants to screw him or herself over, let it happen. We are all adults, this isn't daycare, if someone doesn't want to learn how to work hard, that's their problem. I wish I had more of a hands-off attitude like that sometimes, because I feel like I am letting myself get more stressed about this type of situation than I need to be. But I feel that if all doctors are also teachers, we have a responsibility to help our students find the motivation to work hard, and form good habits. I also feel that I have a responsibility to all the students who do work very hard on rotations, even if it isn't a specialty they want, and it isn't fair that other students slack off and there are no consequences. I know that I had a lot of bad habits as a student, many of which I still struggle with, and it's only with the consistent help of people who cared that I've been able to make any improvement at all in my SOAP note writing or patient presentation. So, I don't want to give up.

I wonder how my parents did it.

I Wish Everyone Lived in La Crosse, Wisconsin

I'm lacking in things to say right now, but this is yet another lovely piece by Dr. Atul Gawande. This time, it's on end of life care and how we choose it and reject it. The article touches on several points, but includes one simple measure that a Wisconsin town took for all patients entering its hospital. It has resulted in a significant reduction in end of life costs.


1. Do you want to be resuscitated if your heart stops?

2. Do you want aggressive treatments such as intubation and mechanical ventilation?

3. Do you want antibiotics?

4. Do you want tube or intravenous feeding if you can’t eat on your own?

Atul Gawande at the New Yorker: Letting Go

Back to the Waking Life

Hurrah! I have survived my two weeks on night float. Everytime I tell someone that, they all sort of imply that it's amongst the worse things you'll have to do as an intern. My experience really wasn't that bad, overall. Perhaps some of that was luck, in that nobody died unexpectedly or suffered because of a massive mistake I had made. Or maybe I just had really decent nurses in the ICU who had my back.

My last two nights, unfortunately, were hell. I realize now that some of that was my own fault, for not knowing when to ask for help in managing tasks. (I also didn't know that I had the right to insist that my senior medical resident physically come down to help me when I needed it for complicated patient problems.) Both nights, my pager exploded at 7 pm with things to do, and many tasks were pushed aside because of acute patients in danger of hemodynamic compromise. As a result, I managed to piss off nurses in the telemetry / step down unit, upset a family because I wasn't able to call them when their family member passed away in the hospice unit two hours before, embarrass myself in front of the surgery team because my medical senior resident had foisted a bogus request onto me, and basically run around as though I was not in any kind of control whatsoever.

When I read back on that, it seems a lot calmer a description than what I went through. After the first busy night, I had a mini-crackdown because I found it so upsetting that everyone was looking to me as if I had answers that I clearly couldn't possibly have because I am just too dumb to be a real doctor. I was upset because someone was rude to me, something I should have been able to handle but instead took as a sign that I was totally on my own. I was glad to have made it through that first night, and was so sure that the evening after would be calm and quiet. Of course, it was just as much madness and it seemed like there was just no respite. On top of having an even more acute patient and multiple other pages come in, a nurse informed me 30 minutes before signouts in the morning that a patient had not received any fluids or food for a full day, and was now reporting severe dehydration. Of course, this patient was also scheduled for surgery, and when I asked them for help with a central line, I got yelled at for not bringing the matter to their attention sooner, and was stuck staying an extra 2 hours longer trying to rectify the many complications associated with the situation.

In fairness, I deserved that reaming. Looking back over the past 2 weeks, there were a lot of things that I overlooked or didn't consider, many fevers I didn't investigate fully, many calls for help I should have made but didn't. Everyday, I felt like the bar was higher, always unreachable. And after those two days, I drove home asking myself if this was what I really wanted. I don't like missing sleep, I don't like feeling gross and messy, I don't like feeling like I've messed up, and I don't like getting yelled at.

But after a few days of getting back to a normal sleep schedule, I remembered that I always doubt whether I want to do surgery when I'm post-call. I always hate getting pushed around or failing. And I love it that much more when I brush myself off and finally win. I love surgery, and I love that it's hard, and I love that it's not something everyone can do. I love getting asked something and realizing that I learned the answer without even realizing it. And ultimately, I chose this. So I've jumped off the cliff, and all I can do is hope for a soft landing.

Singing the Pager Blues

It breaks my heart to say this, but my pager and I are not doing so well. Perhaps I should modify that - my pager and I are a team, but everyone seems to hate us.

Two nights running, now, I haven't been receiving pages. The first night, it was one of the regular floors that kept paging, and then went to the operator when they couldn't reach me. But the odd thing is, the operator's page went through right away. Near the very end of my shift, I got paged by my senior to ask why I wasn't responding to pages from the ICU. Irritatingly, I was sitting at a computer 15 feet from the ICU, checking labs, and hadn't received the page. Last night, I missed a code, although at least that one had an explanation - the operator (who was new) thought that only the intern covering that patient needed to get paged, when in fact ALL interns have to go to the bedside.

Now, most pages you get in the middle of the night are not emergent. Most often, it's just for something small, like renewal of a medication or an order that wasn't written correctly. Occasionally, there's a problem where you do need to go down and check the patient out in person, like blood pressure issues or chest pain concerns. Naturally, in such a scenario, the nurse wants to reach you. But twice now, instead of trying me via the operator, they went straight to contacting my senior resident, which makes me look like The Lazy Intern Who Ignores Pages and Can't Be Trusted. What kills me is that I really do want to go to all of these pages, because I'm still learning as I go and I certainly don't want to miss something important like a heart attack or stroke.

I don't like to complain about technological pitfalls in hospitals, because the fact remains that only 10% of all hospitals in the United States even have EMR systems, and I picked residencies based in poorer inner-city areas because I wanted the experience. But it seems to me that the whole pager system is shockingly inefficient and cost-ineffective. I once did an ob-gyn rotation at a hospital in New Jersey where, instead of pagers, they had in-house cell-phones. They were pretty big and bulky, more like cordless phones, but they worked great because anyone trying to reach you didn't have to wait for you to call-back. There was no question of receiving a page with a hospital extension that didn't exist (I once got paged to the 5th floor, and we don't have one), or trying to call someone back only to find that they had walked away from the phone. If you were busy and running around the hospital, a person trying to reach you didn't have to wait for you to get to a nursing station with a phone not in use. Also, for anyone in a surgical or ob-gyn residency, if you were scrubbed into a case, the circulating nurse could pick up for you and relay the message right away, or even hold the phone to your ear if necessary. It made getting the work done easier for everyone, nurses and residents alike.

Maddeningly, I have tested and re-tested my pager a million times, and it is working just great. Of course, I could just trade the sucker in for a new one, but then I would lose my Hawaii Five-O theme song ringtone. Fortunately, the important nurses (covering the critically ill patients in the ICU) know that I'm serious about wanting to come and help, and aren't angry at me. Last night, I averted the situation by physically going to each floor and making them page me to prove that it was working, and that I did want to come down for anything important. I also made sure they all had the phone number for the girls' call room phone, just in case something didn't go through. But the nurses on the floor are a little bit less invested in making a real effort all of the time, and the last thing I need is talk spreading all over the hospital that I'm the surgical intern who doesn't give a crap.

A Subject Close To My Heart

I don't want to beat anybody over the head in either direction. But the NY Times has a terrific article coming up this weekend on abortion provision in our country, and how shifts in medical education and training for ob-gyn residency has changed our attitudes and ability to access decent care.

NY Times: The New Abortion Providers

My only point is this: it's legal, and women deserve reasonable access to safe procedures without risk of being hassled (either as abortion providers, nurses or patients). We don't hassle transplant surgeons for giving new livers to recovering alcoholics, and we don't hassle psychiatrists for treating sex offenders. Let doctors learn, train and do their jobs without the politics. We all have a responsibility to treat our patients to the very best of our ability, and that means knowing how abortion procedures work and how to manage the care and complications, even if one doesn't plan on providing them in practice. If you don't want people in your community to terminate their unwanted pregnancies, let's all work together on ways to prevent them from happening in the first place.