Driving in the Lazy Gear

24 06 2009

Is it better to be lazy and driven — in other words, determined to succeed with the least effort possible. Or is it better to be terrified and stubborn — in other words motivated by fear and stubborn enough to drag yourself through hell to get where you’re going.

Or is it better to be both?

That’s the crux of my time here in medical school – just wondering if I’ve done enough to get where I’m going. Wondering if I should have been studying 5-6 hours every day, day in, day out. Or have I managed to save enough of myself to make this next two years — the two years everyone has said are the real learning years — manageable.

I guess it all depends on how I did on my boards – so we shall see in a coupla few weeks.

I’m coming to the realization that I’m going to have to buff up my CV pretty heavily here. Now I just need to get into doing it. I’ve got a guaranteed fight on my hands in the next two years…I asked for interesting and challenging…

I’m getting it.





Lies and Regrets

24 06 2009

Her heart barely works anymore.

That’s not to say she isn’t clinging to the life she has left. A ferocious tenor pervades her spirit.

It’s unmistakable. For so long, she’d held onto her health, youth, and virility.

And then she got sick – she had a few heart attacks.

I asked her if she’d smoked. She told me no. I asked about drugs. She said no.
She, I think, lied to me.

She was ashamed and afraid of her mortality – a fear that having your heart literally give out on you tends to impart – a shame that comes with succumbing to an addiction that causes your heart to literally give out on you…

Her husband shot me a question:

“Why is it that doctors come in here, and they ask if you smoke, and tell you not to smoke…”

“yes??”

“and you go outside and you see half of em smoking?”

“It’s not right…I can’t tell you…I just know it’s not right…”





From Axe to Anxious or the Story of Two Pills and $12

9 04 2009

A few years ago…well almost a decade ago now

I was stuck…in a tiny little tube…I was having trouble breathing, sweaty, struggling to move, on my side, bogged down and completely unable to even wriggle forward or backwards…again, I was stuck.

Lt. Green, the salt-fried truck officer yanked me out of the 6 foot long, 13″ square “confined space” tube and quietly shamed me for not being able to overcome such a tiny little obstacle…literally.

He intimated that men whose gut formed pannuses (what is the plural of pannus anways?) that overlapped their thighs could make it through that tube. He marveled – if the fat-bodies could hump their way through it, but I couldn’t – I bristled. I put my mask back on and I flew through that damned tube – I wormed through like a champ.

Fast forward nine years.

My back, which has hurt for the better part of a half-decade, is starting to hurt for more than just a day at a time. I’m always aware of it, the pain much worse now, is at times barely manageable. It’s likely soft-tissue damage and so the obvious thing to do in order to look at the soft-tissues – is to do an MRI.

An MRI is a test where the area to be imaged, in placed in the center of a huge magnet – basically you find yourself in the middle of a tube, while what sounds like a jackhammer thumps and tumbles all around your body. There is about 2″ of clearance all the way around you. It’s a tight fit – at least for me it was…

And it’s been a terrifying fit too. For some reason being on the table on my back, being in the magnet – unable to put my hands up to my eyes or anywhere near my face, over my chest, nothing – is unabashedly terrifying. It conjures up images of some of my most incredible fears – being buried alive. For that reason I’d rather be cremated than anything else – I have no desires to be buried.

I had gone from axe-swinging to anxious. I’d lost the fire in my belly. At least that’s how it’s seemed. I’d love to be able to tell you I finished the test – completely under my own willpower – but in a shockingly powerful way, my brain told ME ,that I wasn’t getting in that tube. At least not headfirst. I wondered if I could jump in the tube feet first. I wondered if I could be knocked out cold with a horse-dose of sedatives.

I’ve thought about losing weight – even going as far as making a bet with a fellow classmate who is entirely too skinny to want to lose weight – to make the tube a less claustrophobic and intimidating place to spend an hour of my time.

I’ve thought about zoning out – pretending I’m in outer space, and that I have to lie perfectly still in order to stay in my oxygen bubble – but that there was ultimately nothing that would keep me calmly lodged in the narrow little tube.

Damn. My doctor prescribed me some sedatives.

The tranquilizers by the way – two pills total, cost me and my insurance company $11.99. They were almost wholly ineffective to boot. I couldn’t help but think that it was why people didn’t go to their doctor – so that he could tell them to buy two expensive ass pills that gave them funky side effects and didn’t really do much to help them feel any better.

So now tangentially, as I’m getting my medication filled – I’m wondering if the exorbitant prices of drugs is one of the driving reasons behind the health disparities that we see in America. I’m wondering if it’s one of the driving reasons behind the amount of chronic disease we see in America – and I’m wondering if it’s the reason that we see people end up completely noncompliant with the regimens that doctors prescribe their patients.

The two pills never even touched the anxiety, the crushing feeling that prompted me to feel like I was suffocating even though I had just drawn in a deep breath of “fresh” air. My stomach tightened and I was having crushing palpitations. Physiologically, I was fighting for my life – my heart fluttering wildly, pupils dilating, and me shaking uncontrollably. I belched and passed gas for a solid ten minutes after the attempt. I walked out in the cool night angry, frustrated with myself and more importantly my head for fearing death in a way I’d always hoped I was immune to.

On tranquilizers, 20 minutes after the procedure had short-circuited a second time due to my overactive limbic system – my pulse was a solid twenty beats a minute above its’ normal. I still felt nauseous. The fight or flight response was still kicked into gear. I wondered what it might be like for those who had random panic attacks when they went about their daily life – doing things like going to the doctor, dentist, post-office. Going to school or the aquarium. At home with relatives, out at a grocery store. On an airplane.

I reflected on the last flight I was on – with a woman who seemed a little edgy and as it turned out she was – fairly afraid of flying – especially through turbulence. Her body language betrayed the shitstorm of fear that was flying through her mind. Her hands clutched out in vain for some sort of safety bar – but then she realized it would’ve been attached to the very airplane she thought was crashing.

A friend of mine summed it up quite succinctly and nicely – “when you are starting to panic, there is a duality in the logic you use to attempt to calm yourself down – you are able to tell yourself that nothing is wrong, and that you are perfectly safe, because there is nothing threatening or harmful happening…but then you realize that even if nothing threatening or harmful is going on – and you feel the way you do, something MUST be wrong, and now you don’t know WHAT it is.”

His understanding made me both laugh, and comforted me.

Now I’m confronting my own mortality. I’ve put on some years, and I’ve begun to learn about all of the myriad ways people can not only die – but degrade and die. I’ve also become much more aware of my place in the world and the world itself. This world is a terrifying and sickening place.

And so naturally, I’ve become more fearful, more anxious in general – and I’m wondering if its’ natural manifestation is via my irrational expression of fears. I’m wondering if I’m doomed to a semi-decrepit body that hurts but isn’t diseased enough to warrant much treatment.

I fear that inattention and slow decline exquisitely. More than ever before I realize the potency and happiness of youth. And I’m very glad I blew all of my money and did as much as I could when I was young. I’m glad I was mostly single – I’m glad I came out of my early twenties and late teens without children or hard committments to anyone other than myself.

But now I have to make sure that in this next few decades, I can learn to live in a fearless manner. They are there – I just need to ignore them. That’s a strength that I’m going to have to develop. As you grow older – the monsters under your bed don’t go away – they just change clothes and get jobs as attorneys or politicians. Or creditors. Or police.

I can’t help but wonder how people feel when they go to the doctor. Do they think they have a crushing super-debilitating illness? Do they feel like its’ going to be a pop-fly illness? Or is it going to be a chronic slog through misery?

Are their physicians going to make it any better? Can their physicians make it any better? How are they going to deal with it? Are their physicians going to even attempt to protect them from their own vulnerabilities and insecurities? Their unique neuroses?

My doctor did. A healthy dose of razzing followed. But he went on and sent me to a physiatrist even though he knows they are going to look at him like he’s not doing his best for not getting me into an MRI. But he did his best – both for the specialist I’m going to see, but also – and ultimately more importantly – for me.





Launch me into space…

1 04 2009

…Was the refrain of a song I was listening to earlier.

It was an almost comedic refrain – but it seemed to resonate with me.

You see, I’m starting to get loopy and sore. Stiff and restless. I’ve been studying now for approximately nine hours. I haven’t really moved around much. It’s prompted a lot of thought actually.

I’m not used to – and never have been used to sitting for nine hours.

Imagine how much I’d weigh if I sat around for nine hours a day, and never walked or went outside…wait a minute…

That sounds like 90% of the population in the U.S.

Scary. So then I started thinking about why I’ve been sitting down for so long – and it’s because I’ve been driving through the pharmacology text in preparation for the boards. I’ve got 195 questions to answer (I wrote them over the last several hours) which will take about three or four more hours I think. This is a break right now.

I’ve covered a multitude of drugs. Beta-blockers, alpha-blockers, alpha agonists, anticholinergics, anesthetics, central nervous system stimulants, anxiolytics. And honestly, it’s all a large soup. And then as I began to take a break – I decided to cruise over to the New York Times Health section – because there’s nothing like taking a break from studying medicine than reading what laypeople have to say about…medicine.

I guess I’m shifting my addictions (Facebook has been excommunicated since the 27th of March). Anyways, I digress.

Midway through reading about all of this pharmacology and trying to learn what some of the adverse reactions are – and what do I see – an article about polypharmacy. Which is a big problem in the U.S.

A huge problem…Haha – actually like the massive patients that tomorrow’s physicians (me and my peoples) will treat.

Suddenly I began to realize how much more important research and making it as efficient as possible is. It’s the only place that major breakthroughs in health are going to come from.

On another note – I’m amazed at how much more time I have now that I’ve decided to cast aside facebook. I’m using twitter much more – but honestly – the amount of time I spent on Facebook basically academically crippled me over the last two years…I can’t help but think I’m supposed to know so much more of this stuff…

oh well…
do work…

ciao





Hard work

30 03 2009

So, I’m effectively cut off from the Internet and going through computer withdrawals.

I’m typing this from my iPhone. Thank God for my iPhone.

My post today is about hardwork. The kind that makes other people say – dude that’s insanity, slow down just a bit. It’s my style – excitedly working on getting myself somewhere – diet coke in hand, charging hard through the thickets of work that interect themselves into my day. I’m by nature a bipolar person when it comes to work. I either want to – or I don’t. Spring is the time when I want to the least and fall is probably when I’m at my best… At least that’s my thought…

I recently decided to claim my rightful place in a top-notch residency. I’m smart enough for it…now I just have to work hard enough for it…

Three days outside of Facebook and while I sadly miss it – I’m on the way to making up for it with a vengeance…I can do this all day and night long.

I have two more weeks to be here…I’ve gotta make them count like there’s no tomorrow…because while that statement is a stretch – there is some truth in it…we aren’t measured in life by what we’re GOING to do. Or what we plan to do…We’re measured in life by what we’ve done.

That basically sums up this entire post. I’m not going to fight to get back west. I’m FIGHTING to go back west.

Nuff said, it’s time for a self-imposed drill school

Discipline is my friend…Discipline is my friend…





Blinded Professionalism

16 03 2009

It’s funny, reading in the NYTimes today – business schools are scratching their heads. They want to figure out exactly where they went wrong. The economic collapse has left them wondering what’s next – and why exactly their proteges and products didn’t see it coming and couldn’t steer their respective ships – read: companies – away from the brink of the financial abyss that opened up on Wall St.

I can’t help but draw analogies to the current state of medical education and medicine. We send people to medical school for 4 entire years and expect them to come out competent physicians. But anyone who knows anything about medicine knows that you don’t want to be anywhere near a hospital on July 1st. Why?

It’s the day all of the recent medical graduates start their internships and residencies. And they are brand spanking new.

Beyond the basics of figuring out what they are doing organizationally – these graduates are developing their chops, diagnostically and treatment wise.

But isn’t that what they were supposed to do in medical school? Aren’t they supposed to know how to diagnose and treat – from day one? Isn’t this a time for familiarity with the intricate details?

Well, what’s funny – is that brand new doctors are a little bit like puppies. They are familiar with how to sniff, scratch, and suckle. They’ve got the tools they need – they’re just blind for a few weeks. A friend of mine – whose halfway through the first year of her surgical internship – put it best:

“I’m nowhere near the retard I was in July.”

Odd thing to hear a doctor say.

What it would naturally prompt one to question is – what exactly are student physicians learning?

Well it seems a whole lot of minutiae – with no framework of where to put it. And very little repetition. There’s a worthless statistic floating out there that says factoids must be repeated seven times before they stick in long-term memory. Over the four years that medical school consumes of a doctors life – they may hear the obscure, extremely important “trivia” four or five times…but it may not stick.

There is good reason for the minutiae – unfortunately, many medical schools (mine included) do not utilize technology to reinforce the important little lessons, nor cement them in the memory of young physicians by providing the rationale for knowing the facts.

Another shocking quote we heard on day one of medical school: “You’ll forget 50% of what you learn within a year of learning it…of the 50% that you remember, half of that will be wrong in 10-15 years.”
Well why teach it in the first place then?

There’s a quote in the article above where Warren Bennis, a professor of management says business schools suffer from “an overemphasis on the rigor and an underemphasis on relevance.” He goes on to say, “Business schools have forgotten that they are a professional school.”

He could be talking about medical schools…





Caught in the imperfections…

22 01 2009

It was a good thing he passed out when he did.

If he’d made it home, he likely would have died right there – his red blood cells bursting under the burden that his white blood cells were putting them under.

If he’d been somewhere private, his bizarre behavior and drunken, stuporous gait wouldn’t have been noticed.

He says he fell. EMS says he was taking his clothes off in the snow, screaming obscenities, and running through rush hour traffic. They brought him in, and an ER intern, groping in the dark for a diagnosis – blindly ordered almost every single test they could think of…they did the medical version of “throwing the book” at somebody…

Turns out, this guy had a rare blood disorder – Thrombotic Thrombocytopenic Purpura – one that strikes about 4 to 6 OUT OF A MILLION per year. If undiagnosed, it’s fatal 95% of the time. If undiagnosed, a patient can die in days…sometimes hours…

When we saw him, he was weak – the only thing he remembered was the vivid dreams and hallucinations he had while he was still being stabilized and was restrained – and still unclear on the majority of the details of his illness… He thought he had been in the hospital for five days – he’d been there closer to twenty.

Our resident told us that it was a lucky thing that he was diagnosed. Our resident told us the reason he was diagnosed was because the ER intern ordered a “shotgun panel”. A shotgun panel is a group of blood tests done when a physician doesn’t know what’s going on and in trying to figure out what’s going on, tests for just about everything.

Our patient got caught in the cracks, and it saved his life.

What’s funny, is that those same exact cracks – shotgun panels, intern physicians without the benefit of a more experienced, and present attending physician – are what cost the medical system a TON of money every year, and are threatening to swallow the rest of the US economy.

I spoke with a friend in law school, and asked what their thoughts on medical malpractice lawsuits were – their answer was that pressure due to lawsuits was getting physicians to practice defensive medicine, which is a “good thing” – sort of like defensive driving.

But to many physicians, defensive medicine is anathema. It is what swallows hospitals whole – physicians so afraid of making mistakes and being sued, that they subject patients to painful, unnecessary testing. MRIs when CTs could suffice. CT scans when an x-ray would do. Blood work, DNA testing, biopsies. Medical testing makes up one of the largest expenditures in the US. Defensive medicine, in the purview of many docs, means you don’t know what’s going on – and you aren’t going about the best way of treating the patient.

Sometimes, that’s an acceptable position – unintelligible or non-communicative patients, green doctors (a.k.a. interns /slave labor), exceedingly rare medical conditions – from an academic standpoint…it’s almost understandable given the conditions. But from a legal standpoint, there is no excuse for not knowing – even though the practice of medicine is akin to reading a half written science textbook with beer goggles on…

So there is this large disconnect – the financial pressures of malpractice lawsuit driven behavior (defensive medicine) does not connect up with the medical systems aims and goals. It also does not connect with the medical reality of patients that do not faithfully follow textbook patterns of disease. It also does not connect with the scientific reality that our state of knowledge is woeful at best.

One of the first things that was said to us when we started school was “Half of what you are going to learn is wrong – the problem is, we don’t know what half…” It’s like living by a constantly changing bible that you are expected to have memorized… So until we get a medical system that asserts its’ right to be make mistakes without being penalized monetarily, until we get a legal system that can differentiate between simple professional mistakes or mis-communications and mistakes that extend into the realm of criminal negligence or manslaughter, and until we figure out a way to check increasing medical test costs – we won’t have universal health care, and unfortunately, since prevention is the best medicine – we’ll continue to get sicker as a nation.

But for now, for people like my patient today – the response to the cracks in our broken system were ultimately what saved his life…





Insights from 1 year, 4 months, 2 weeks and 3 hours in

10 01 2009

- I need to study at a desk…

- I need music and light snacks to study with…

- I should preferrably be somewhat cool (temperature)…

- People cannot be walking by, nor tugboats for that matter – movement in my general direction is a poor predictor of successful studying…

- I cannot be trusted with a highlighter…nor a ruler and a pen…

- Always memorize the tables in the books…

- Always memorize the slides…

- Always memorize things that are italicized, underlined, bold, or have a catchphrase such as “it is important to remember…” or “it is dangerous to…” or “the patient may die if…”

- I should make algorithms using lab data/history/physical findings for each system and complaint…

- Animations make oodles more sense than textbooks…

- Pictures are good – words are a double edged sword…they’re sorta like electrolytes…or antibodies…

- It’s actually a good thing to live so close to school…Frustrating, demoralizing, alternately soul-crushing and soul-draining…but occasionally its’ sorta convenient…

- I cannot afford to not pay attention to things like laundry, haircuts, cleaning, writing, photography, eating, or exercise – if I don’t learn how to cram them in now, I never will…

- Every hour I need to stand up, stretch, breathe, and refocus myself…

- Writing and exercising is therapeutic…

- Lectures are absolutely worthless – attendance is in fact somewhat detrimental…small groups range from marginally beneficial to completely useless…

- Studying for boards is going to suck a lot…

- Medical school is designed to be an uphill battle the entire way – a series of seemingly endless struggles punctuated by repeated failures…

- I’m on a roll…





I should probably say this…

10 01 2009

To all of my friends and family who is reading this.

I’m sorry if I’ve been short, or if in the future I am short with you. Medical school, more than anything, just by virtue of the sheer inefficiency of the process is extremely time consuming.

I think medicine is that way as well. It’s really too bad school isn’t more condensed and better run. It doesn’t need to take 2 years, and it doesn’t really need to take a long time to understand all of the basic science concepts.

But here it does. Here we are supposed to extract knowledge from a dry and overly verbose text. Not too much in the way of animations – funny how one simple animation with wisely placed captions and simple explanations and a few miniature review questions seems to simplify everything and make the whole process of learning “difficult” material easier to learn.

But seriously, I’ve been short with many of you.

I haven’t stayed in contact with many of you.

And you all deserve better of me – I’m truly sorry if I’ve hurt anyone.





Ma’am he’s already dead

7 01 2009

She was sitting in the corner reading her bible.

We shuffled in, all of us, and because our resident told us that she was afraid of infection, we all made a show of scrubbing our hands with antiseptic lotion before even entering the room.

He was lying there, intubated. He would cough occasionally, the alarms on the respirator would go off occasionally, and then he would settle back down. He had a few IVs, and the site of the tube was in through the front of his neck. She didn’t want us to touch him out of fear that he wouldn’t be able to fight his infection any longer. Out of fear that he might die prematurely.

He already had.

About 8 years prior, he was a vibrant young man. He was popular. He was also into drugs. And about 8 years ago, almost to the date he overdosed. He slipped into respiratory arrest first, his brain no longer interested in breathing. Almost as if he’d forgotten how to breathe. From there he slipped into cardiac arrest before it was discovered that he’d overdosed. He’d been in cardiac arrest for a short time – 5 to 8 minutes before he was discovered and before CPR was started.

He recovered a rhythm on the way to the hospital. He was later able to breathe on his own. He hasn’t walked or talked since that day. He lives in a nursing home nowadays where they feed him pureed food because he cannot chew. He cannot write or use either of his hands. They rest near his clavicles because of the spasticity that his massive brain damage caused. He has no meaningful motor function. He also does not respond to verbal questions or commands. He cannot make eye contact, nor can he even control which direction his eyes point . About the only things he can do are breathe and swallow.

A few days ago he was discovered coughing wildly, and sweating profusely. His caretaker got him admitted to the hospital where he was put on a trial of antibiotics and eventually intubated and put on a respirator for a florid case of pneumonia. As the infection finally started to clear up, his doctors tried to wean him off of the respirator. It didn’t work. So they moved his intubation site to his neck, to alleviate the stress on his respiratory system of having all of the oral secretions make their way down (apparently you make 1 liter of saliva every day).

So now he lies there, helpless, unproductive, comfortable.

And it made me angry.

It made me angry that he had figuratively blown his brains out. Insurance is what pays for his nursing home care. Those costs are passed onto me in the form of higher premiums. It made me angry that because he is in the position he is, friends of mine at the opposite end of the spectrum are unable to afford medical care. You see, some of his care is charity care – but the fact remains that there are others who have problems that I feel more sympathetic to.

I was angry that I felt like I could judge the value and quality of his “life” in such black and white terms. It didn’t seem gray to me at all – he’d done it to himself, and now he was stuck in a place where he wasn’t at all able to help society in any manner. 150 years ago we thought that black people were 3/5ths human beings. What are we wrong about today? Consciousness?

I found myself confused. I found myself angry and hoping that our patient was somehow getting more out of the encounter than he appeared to be. I was hoping that he had some form of consciousness that was overall a positive experience. I was hoping that he was perhaps in a state of consciousness similar to the one that neonates are when they are in the womb, or immediately after birth. Part of me hoped that he was still high – floating blissfully through the rest of his state and society sponsored life.

I just hoped that it was worth it. I couldn’t reconcile what would be better or worse – to allow his physical body to pass on, and utilize the resources for people who are alive and awake who can continue to exchange with the rest of the world – OR to let him lie there comfortable until the time when he does finally die and use those much needed resources to help this young man.

He was a young man when he died – only 21. He’s now 29.

The person who made the decision to keep him from passing away is his mother. She would have no talk of “allowing nature to take its’ course” when the pneumonia made a respirator the only course of action capable of keeping him alive physically. Deeply religious, she sat quietly, clutching her rosary beads, reading her bible the entire time we were there. Our resident told us that she’s been praying for twenty minutes every hour every day to make sure he doesn’t die.

All I could think was: Ma’am, he’s already dead.