I'm on campus today studying for Step 2, the first time I've been on campus since the Aurora shooting 10 days ago. It was a bit of a shock to me seeing the heightened security and having to show my ID badge to get into the building in which I took all my classes during the first two years of medical school.
I set up shop in a corner room on the second floor, quiet with lots of natural light. It also has a view of the main flagpole standing over the main entrance to campus. The flag was still at half-mast when I arrived this morning, but sometime during my first or second problem sets, the flag was raised back to the top. A sign of this community trying to move on.
Monday, July 30, 2012
Tuesday, July 24, 2012
Oral presentation without notes
Today I had to present a new patient from memory. The team split up in the morning, half going to clinic and the other half rounding quickly on patients. I only had two patients to present, one of which was a new patient I had seen yesterday with an intern and still needed to be staffed with the attending. I realized after it was too late that my intern had taken the History & Physical with her to clinic.
Given my previous struggles with oral presentations, I was a little worried about how this presenting-without-notes thing would play out. To my surprise, though, I not only pulled it off but gave a thorough, concise, and conversational presentation (in my humble opinion). What's more is that the senior attending from another team happened to be at the patient's room and stayed specifically to listen to my presentation, so I had an audience.
It felt good to get it right.
Numerous attendings have told me that the best way to improve my oral presentation is to present without notes. That seemed like an impossible task a few years ago but within reach now that I have some more clinical experience under my belt. I'm going to take their advice now and try to present patients with as little help from notes as possible.
Given my previous struggles with oral presentations, I was a little worried about how this presenting-without-notes thing would play out. To my surprise, though, I not only pulled it off but gave a thorough, concise, and conversational presentation (in my humble opinion). What's more is that the senior attending from another team happened to be at the patient's room and stayed specifically to listen to my presentation, so I had an audience.
It felt good to get it right.
Numerous attendings have told me that the best way to improve my oral presentation is to present without notes. That seemed like an impossible task a few years ago but within reach now that I have some more clinical experience under my belt. I'm going to take their advice now and try to present patients with as little help from notes as possible.
Sunday, July 15, 2012
Zebra hunter
Working on a consult service is very different than taking care of my own patients. The primary care team calls up neurology when they think that a patient of theirs has neurological problems. The neurology team evaluates the patient, gives the primary team a set of recommendations, and follows the patient until the neurological issues are resolved.
Over the past two weeks, I have seen what a "good" consult looks like and what a "bad" consult looks like. A "good" consult has a true neurological problem with a clear question for the neurology team.
We had a "bad" consult the other day that was essentially, "I think my patient has corticobasilar degeneration," a neurodegenerative disorder similar to Parkinson's disease but much more rare. The resident who ordered the neurology consult anchored onto a very rare neurologic diagnosis and basically wanted the neurology team to confirm his diagnosis.
On exam the patient did indeed have some parkinsonian signs and symptoms, but he was also taking some medications that could potentially cause those symptoms.
My neurology resident got frustrated when he was pressed on corticobasilar degeneration. He finally told the primary care resident (in a very professional manner) that the neurology recommendations would be the same regardless of whether the true diagnosis ends up being corticobasilar degeneration, Parkinson's disease, or drug-induced parkinsonism: Discontinue all medications that could cause parkinsonian symptoms and re-evaluate the patient in two days.
This could have been a "good" consult if it was worded differently: "I have a patient with intention tremor, small handwriting, and cogwheel rigidity who is also taking psychotropic medications. Our team wants you to evaluate the patient to rule out Parkinson's disease or parkinsonian variants."
Aside from learning what good and bad consults sound like, I also learned that one quickly develops a reputation based on behavior like this. When my resident staffed this patient with the neurology attending, the attending interrupted to ask, "Is this the zebra hunter resident who ordered this consult?" His reputation had preceded him.
Over the past two weeks, I have seen what a "good" consult looks like and what a "bad" consult looks like. A "good" consult has a true neurological problem with a clear question for the neurology team.
We had a "bad" consult the other day that was essentially, "I think my patient has corticobasilar degeneration," a neurodegenerative disorder similar to Parkinson's disease but much more rare. The resident who ordered the neurology consult anchored onto a very rare neurologic diagnosis and basically wanted the neurology team to confirm his diagnosis.
On exam the patient did indeed have some parkinsonian signs and symptoms, but he was also taking some medications that could potentially cause those symptoms.
My neurology resident got frustrated when he was pressed on corticobasilar degeneration. He finally told the primary care resident (in a very professional manner) that the neurology recommendations would be the same regardless of whether the true diagnosis ends up being corticobasilar degeneration, Parkinson's disease, or drug-induced parkinsonism: Discontinue all medications that could cause parkinsonian symptoms and re-evaluate the patient in two days.
This could have been a "good" consult if it was worded differently: "I have a patient with intention tremor, small handwriting, and cogwheel rigidity who is also taking psychotropic medications. Our team wants you to evaluate the patient to rule out Parkinson's disease or parkinsonian variants."
Aside from learning what good and bad consults sound like, I also learned that one quickly develops a reputation based on behavior like this. When my resident staffed this patient with the neurology attending, the attending interrupted to ask, "Is this the zebra hunter resident who ordered this consult?" His reputation had preceded him.
Tuesday, July 10, 2012
Immature
My neurology attending is a big kid dressed up in a suit and tie and a white coat. Don't let the gray hair fool you.
There's a line of tape on the ground in clinic, to help evaluate gait in patients. Today he jumped on the line, arms spread wide, walking it like a tightrope with an exaggerated wobble. Then he banked hard to the left around a corner, made an engine revving sound, and yelled "Airplane turn!"
He turned around and flashed a grin. "You're never too old to be immature!"
I can't wait until I'm established enough to get away with letting out my inner kid like that.
There's a line of tape on the ground in clinic, to help evaluate gait in patients. Today he jumped on the line, arms spread wide, walking it like a tightrope with an exaggerated wobble. Then he banked hard to the left around a corner, made an engine revving sound, and yelled "Airplane turn!"
He turned around and flashed a grin. "You're never too old to be immature!"
I can't wait until I'm established enough to get away with letting out my inner kid like that.
Monday, July 2, 2012
First day of neurology elective
Change of plans:
Originally, I scheduled child psychiatry for July. Over the past few months, though, as I've been talking with some of my classmates who are going into neurology, I began regretting the fact that I never got a taste of adult neurology. What if it's substantially different from child neurology, and what if I really like it? Like it enough to perhaps make a career out of it?
Regardless of the low likelihood that I will actually go into neurology, I decided last-minute to switch my child psychiatry elective for neurology. At the very least, neurology is very relevant to the combined practice of medicine and psychiatry.
My day started at 7am, as will all weekdays this month. I had only one patient to round on in the morning, then I had only one consult patient in the afternoon. My resident told me to go home at 3:30. I don't expect every day this month to be this slow, but it's definitely a change of pace from last month.
Originally, I scheduled child psychiatry for July. Over the past few months, though, as I've been talking with some of my classmates who are going into neurology, I began regretting the fact that I never got a taste of adult neurology. What if it's substantially different from child neurology, and what if I really like it? Like it enough to perhaps make a career out of it?
Regardless of the low likelihood that I will actually go into neurology, I decided last-minute to switch my child psychiatry elective for neurology. At the very least, neurology is very relevant to the combined practice of medicine and psychiatry.
My day started at 7am, as will all weekdays this month. I had only one patient to round on in the morning, then I had only one consult patient in the afternoon. My resident told me to go home at 3:30. I don't expect every day this month to be this slow, but it's definitely a change of pace from last month.
Sunday, July 1, 2012
Happy ERAS day!
Today the Electronic Residency Application Service (ERAS) opened for the Class of 2013. Thus begins yet another epic application process, this time for residency.
ERAS has five main components:
ERAS is open only to medical students until September 15th, at which point applicants are allowed to submit their application. The few residency program directors I talked with strongly encouraged me to submit my ERAS application on September 15th, rather than waiting, because they like to start sifting through the applicants and offering interview immediately.
ERAS has five main components:
- Curriculum vitae: General information, education and training, publications, awards and honors, extracurricular and volunteer activities.
- USMLE transcripts: Step 1 and Step 2.
- Personal statements: There aren't any limits to how many personal statements can be written and uploaded, but only one personal statement can be assigned to each program.
- Letters of recommendation: There aren't any limits to how many letters of recommendation can be uploaded, but a maximum of four letters of recommendation can be assigned to each program.
- Program selection: There aren't any limits to how many programs can be selected. Also, multiple specialties can be selected. Then, for each program, the specific personal statement and letters of recommendation are assigned.
ERAS is open only to medical students until September 15th, at which point applicants are allowed to submit their application. The few residency program directors I talked with strongly encouraged me to submit my ERAS application on September 15th, rather than waiting, because they like to start sifting through the applicants and offering interview immediately.
Saturday, June 30, 2012
Smart choice
Earlier this week, I forgot my bike helmet when I left the hospital. There I stood outside the hospital, looking at my bike, trying to decide whether I should go back upstairs to get my helmet or just bike home without it. I was tired and really, really wanted to just go home. But I turned around and went upstairs to get my helmet.
On the elevator ride back down, the elevator stopped at the surgery floor. A man about my age limped inside the elevator. He had a black eye, his mouth was swollen on one side, and he was leaning on a single crutch. He looked down at my helmet and said, "Smart choice. A car hit me a month ago. They had to take out two feet of my small intestine, and I banged my head pretty good."
"Were you wearing a helmet?" I asked, a stupid question because I already knew the answer.
"No."
The elevator doors opened to the ground floor. I thanked the man for sharing with me and wished him a speedy recovery. Then I walked away on two good legs, carrying an atraumatic head on my shoulders, thankful that I decided to go back upstairs for my helmet.
On the elevator ride back down, the elevator stopped at the surgery floor. A man about my age limped inside the elevator. He had a black eye, his mouth was swollen on one side, and he was leaning on a single crutch. He looked down at my helmet and said, "Smart choice. A car hit me a month ago. They had to take out two feet of my small intestine, and I banged my head pretty good."
"Were you wearing a helmet?" I asked, a stupid question because I already knew the answer.
"No."
The elevator doors opened to the ground floor. I thanked the man for sharing with me and wished him a speedy recovery. Then I walked away on two good legs, carrying an atraumatic head on my shoulders, thankful that I decided to go back upstairs for my helmet.
Friday, June 29, 2012
Recognition
I went out to a wine bar this evening to celebrate the end of my Internal Medicine sub-internship. As I was looking around for a table, a woman sitting at a table behind me said, "Excuse me, are you a doctor?" She was holding a baby.
My first thought: "Oh no, is she going to ask me for medical advice?" My second thought: "Hmm, she looks familiar." I said no, I'm not a doctor.
"Are you a doctor in training?"
"Yes..."
"You delivered my baby. In fact you caught him."
I took a closer look at the woman, then at her husband sitting across the table from her, and I suddenly remembered them. I did indeed care for her when I worked on Labor and Delivery, and I did indeed catch her baby. I even cut his umbilical cord. And there he was, sitting in his mother's lap peacefully sucking away at a bottle, a healthy two-month-old boy.
"Can I see him?" I ooohed and ahhhed and ogled over this little boy who I helped bring into this world. I said my congratulations to the lucky parents, thanked them for recognizing me and saying hi, then I sat down at my table, glowing.
Finishing my Medicine sub-internship today felt pretty awesome, but this moment by far made my day.
Later in the evening, the waitress came over to say, "Your glass of chardonnay is on the little baby boy at that table." I smiled and raised my glass to them from across the room to say thank you. And I almost cried.
My first thought: "Oh no, is she going to ask me for medical advice?" My second thought: "Hmm, she looks familiar." I said no, I'm not a doctor.
"Are you a doctor in training?"
"Yes..."
"You delivered my baby. In fact you caught him."
I took a closer look at the woman, then at her husband sitting across the table from her, and I suddenly remembered them. I did indeed care for her when I worked on Labor and Delivery, and I did indeed catch her baby. I even cut his umbilical cord. And there he was, sitting in his mother's lap peacefully sucking away at a bottle, a healthy two-month-old boy.
"Can I see him?" I ooohed and ahhhed and ogled over this little boy who I helped bring into this world. I said my congratulations to the lucky parents, thanked them for recognizing me and saying hi, then I sat down at my table, glowing.
Finishing my Medicine sub-internship today felt pretty awesome, but this moment by far made my day.
Later in the evening, the waitress came over to say, "Your glass of chardonnay is on the little baby boy at that table." I smiled and raised my glass to them from across the room to say thank you. And I almost cried.
Sunday, June 3, 2012
Medicine sub-internship at Denver Health
I start my Internal Medicine sub-internship tomorrow morning. I decided to do my medicine sub-internship at Denver Health for two main reasons:
First, as a county hospital, Denver Health is the safety net for disadvantaged people who have slipped through the cracks of our broken healthcare system. Such a patient population almost by definition includes a high proportion of people with drug addictions, cognitive impairment, psychotic illnesses, and many other psychiatric comorbidities.
Second, since I also completed my psychiatry sub-internship at Denver Health, this will allow me to more directly compare my psychiatry and medicine sub-internship experiences. Will I enjoy this medicine sub-internship as much as I enjoyed psychiatry? How will this medicine sub-internship influence my feelings about applying to combined medicine/psychiatry residency programs?
While I expect that my plans won't change much as a result of my medicine sub-internship, the possibility remains that two months of back-to-back psychiatry and medicine may clarify which field I'm more passionate about.
First, as a county hospital, Denver Health is the safety net for disadvantaged people who have slipped through the cracks of our broken healthcare system. Such a patient population almost by definition includes a high proportion of people with drug addictions, cognitive impairment, psychotic illnesses, and many other psychiatric comorbidities.
Second, since I also completed my psychiatry sub-internship at Denver Health, this will allow me to more directly compare my psychiatry and medicine sub-internship experiences. Will I enjoy this medicine sub-internship as much as I enjoyed psychiatry? How will this medicine sub-internship influence my feelings about applying to combined medicine/psychiatry residency programs?
While I expect that my plans won't change much as a result of my medicine sub-internship, the possibility remains that two months of back-to-back psychiatry and medicine may clarify which field I'm more passionate about.
Sunday, May 27, 2012
Ethical ambiguity: When to certify a psychiatric patient
The greatest difficulty I've had during my psychiatry sub-internship is deciding when to take away someone's personal freedom by placing them on a mental health hold (MHH) or a short-term certification (STC). My attending told me at the beginning of the rotation, "I want you to make decisions about your patients. We'll do what you want, so long as you can explain why you're doing it and you have your head screwed on straight."
This responsibility hit home a few weeks ago when I knocked on my attending's office door to talk with him about a patient. I was uncertain about whether to place this patient on a STC. My attending sat back in his chair and listened while I explored both sides of the argument.
On the one hand...
This is a middle-aged guy with an unclear history of psychosis who's experiencing paranoid delusions to the extent that he has isolated himself from the entire world, including his family. He has a history of attempting suicide, and there is evidence of increasingly bizarre and disorganized thoughts. According to the police who originally placed him on a MHH, the patient's apartment was a disaster. Charcoal briquettes were placed around the periphery of each room, bed and couch and lamps were turned upside down, curtains were turned inside out, and two pennies were placed in strange places like in the refrigerator and in the shower. This is a man who could certainly benefit from continued hospitalization and treatment.
On the other hand...
The patient does not want to stay in the hospital, does not want treatment, and does not believe he has a mental illness. He shows no depressive symptoms and denies wanting to hurt himself or other people. He sure has some bizarre and paranoid thoughts, and doesn't have a job, but he pulls in a Social Security disability check each month and is able to clothe and feed himself. He may or may not meet legal criteria for being "gravely disabled," which would justify holding him on a STC.
When I finished, my attending leaned forward, looked at me intently, and asked, "So, what are you going to do?" I understood what he was doing: pushing me to make a tough decision and stick by it. This is part of my education, the process of becoming a doctor.
"I don't know, that's why I came to you for advice."
"Do you think this patient is mentally ill and needs treatment?"
"Yes."
"Do you believe that he is a danger to himself or others?"
"No."
"Do you believe that he is gravely disabled?"
"Possibly."
My attending then advised me to remember that my primary responsibility is to my patients. As long as I believe that I am following the law, I should do what I think is necessary to take proper care of my patients and let the judge decide if our actions should be upheld.
"So, what are you going to do?" my attending asked again, this time with an amused smirk.
"I'm going to cert him."
Although he never explicitly said so, it was clear to me that my attending thought that we should keep this patient on a STC. I made the decision, though, based on my gut feeling that my patient was indeed gravely disabled and would benefit from treatment.
The patient stayed for another week with nominal improvement of his paranoia and disorganization. He agreed to keep taking medications after he left the hospital. That was something.
Everything about this patient's case was ambiguous to me. Did I really help him by keeping him in the hospital against his will? Was I justified in holding him on a STC? Was he really gravely disabled? Sometimes there are no clear answers, and I just have to make a decision that seems best at the time. I feel better knowing that I would make the same decision again if I had to do it over.
This responsibility hit home a few weeks ago when I knocked on my attending's office door to talk with him about a patient. I was uncertain about whether to place this patient on a STC. My attending sat back in his chair and listened while I explored both sides of the argument.
On the one hand...
This is a middle-aged guy with an unclear history of psychosis who's experiencing paranoid delusions to the extent that he has isolated himself from the entire world, including his family. He has a history of attempting suicide, and there is evidence of increasingly bizarre and disorganized thoughts. According to the police who originally placed him on a MHH, the patient's apartment was a disaster. Charcoal briquettes were placed around the periphery of each room, bed and couch and lamps were turned upside down, curtains were turned inside out, and two pennies were placed in strange places like in the refrigerator and in the shower. This is a man who could certainly benefit from continued hospitalization and treatment.
On the other hand...
The patient does not want to stay in the hospital, does not want treatment, and does not believe he has a mental illness. He shows no depressive symptoms and denies wanting to hurt himself or other people. He sure has some bizarre and paranoid thoughts, and doesn't have a job, but he pulls in a Social Security disability check each month and is able to clothe and feed himself. He may or may not meet legal criteria for being "gravely disabled," which would justify holding him on a STC.
When I finished, my attending leaned forward, looked at me intently, and asked, "So, what are you going to do?" I understood what he was doing: pushing me to make a tough decision and stick by it. This is part of my education, the process of becoming a doctor.
"I don't know, that's why I came to you for advice."
"Do you think this patient is mentally ill and needs treatment?"
"Yes."
"Do you believe that he is a danger to himself or others?"
"No."
"Do you believe that he is gravely disabled?"
"Possibly."
My attending then advised me to remember that my primary responsibility is to my patients. As long as I believe that I am following the law, I should do what I think is necessary to take proper care of my patients and let the judge decide if our actions should be upheld.
"So, what are you going to do?" my attending asked again, this time with an amused smirk.
"I'm going to cert him."
Although he never explicitly said so, it was clear to me that my attending thought that we should keep this patient on a STC. I made the decision, though, based on my gut feeling that my patient was indeed gravely disabled and would benefit from treatment.
The patient stayed for another week with nominal improvement of his paranoia and disorganization. He agreed to keep taking medications after he left the hospital. That was something.
Everything about this patient's case was ambiguous to me. Did I really help him by keeping him in the hospital against his will? Was I justified in holding him on a STC? Was he really gravely disabled? Sometimes there are no clear answers, and I just have to make a decision that seems best at the time. I feel better knowing that I would make the same decision again if I had to do it over.
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