do no harm
Now I have no idea what this attending is like, but avoiding a code is not surprising. For one thing, if he is not a critical care attending or an anesthesiologist, he is likely to do more harm than good. Which is ridiculous, if you consider the fact that senior residents, regardless of specialty, are expected to run codes without skipping a beat.
But seriously, nowhere is it more apparent that you use it or lose than in medicine. After all, there are psychiatrists who don't remember what Marfan Syndrome is, there are rehab docs who couldn't hit an LP even if the spinal column were exposed because of a sacral decubitus. There are internists who wouldn't be able to find an appendix if it slapped them across the face. (Seriously. An appendectomy in the hands of even a 2nd-year surgical resident would probably only take 15 minutes. Some of my more cocky but quite technically skilled classmates could probably do it in 30 minutes. My dad, who was trained in Internal Medicine in the Philippines, where there is no such thing as malpractice, was recruited by an attending internist to do an app'y. It took them more than 2 hours. And the patient had to be transfused twice.) And I dare you to ask a surgeon to manage hypertension. (To steal a line from a surgical resident I once worked with, I wouldn't wish that on my worst enemy.) Pediatricians freak out when confronted with chest pain in an adult—a pediatrician's worst nightmare is to be on an airplane when a flight attendant comes up to them and asks if they're a physician, and if so, could they please help with a "situation." An ER doc's solution to a headache is essentially a CT head without contrast and then an LP if it's normal, even if the patient repeatedly tells them that they're there because they ran out of sumitriptan, unfortunately agreeing to the statement that this is the worst headache of their life.
So. As I mention in my last post, especially in the ICU, chances are that the nurses know how to run a code better than the average physician.
While surgeons and ER docs often have different ideas, there is a lot of practical application of the dictum of "Do no harm." This is an internist's central credo, and is perhaps the only thing that prevents them from going absolutely mad in the face of the insanity of our health care system. This is the reason why an internist is most likely to "wait and see." This is why internists aren't really big on intervening. Their favorite medication is tincture of time. Their favorite procedure is watchful waiting. In our lawsuit-happy culture, "do no harm" also translates into "don't meddle when it's none of your business." After all, codes are what they pay residents for. In a non-teaching setting, codes are what they pay the house physician for. This is why code pagers exist. Codes are why some attending anesthesiologists have to take in-house call. There is nothing worse than seeing an attending internist run to a code, try to intubate a 500 lb patient, and fail miserably, over and over again, getting blood-tinged drool all over himself as the patient progressively turns blue, the monitors beeping wildly as O2 sats drop, then the heart rate accelerating to some rate too fast to be merely sinus tach, the rhythm strip completely worthless as everyone is literally jumping on the patient's chest. At this point, the internist is running a cold sweat, looking a little hypotensive himself, in danger of having an episode of syncope, until the anesthesiologist shows up, gently takes the ET tube from the internist's shaking hands, and one-handedly shoves it down to just above the carina on the first try.
And then—in the long run—who says if coding someone is really the most compassionate thing to do? Especially in internal medicine. Not to sound crass, but guys who are in multi-system organ failure probably don't really want to be returned to consciousness, returned to suffering that couldn't be controlled even if you covered their body entirely with fentanyl patches. Remember, if you can't restore someone's pulse in 8 minutes, or get their sats up to a reasonable level, then they are going to suffer irreversible brain damage. This doesn't mean you should give up, because people with full-blown hemiparesis can still live productive lives, but as the clock continues to tick after 8 minutes, the patient's quality of life probably diminishes in a logarithmic fashion. (Not that I've found an actual reference, but you get the point.) By 20 minutes, any attempt of resuscitation is absolute cruelty and probably unethical and possibly illegal (especially if you happened to overlook that DNR/DNI tag.)
And, of course, remember. Doctors are people, too.
16:46 · permalink · add a comment
Tue, 24 Feb 2004 topin vs out
It struck me today how somewhat ludicrous medical school is, in the sense that it does very little to expose you to what real life (for most doctors) is going to be like. I suppose that's not really the point of medical school, though. As a wise 4th year (now intern) once told me, the realistic natural progression goes something like this, paralleling a SOAP note (for the improbable non-medical readers of this site, the acronym stands for Subjective, Objective, Assessment, and Plan). 3rd year teaches you how to do the subjective and objective competently. In other words, the only real expectation is to be able to do an H&lP [history and physical] competently. An, in reality, in some ways the bar is even lower than that (although not really, because I think this is a really sublime skill that even some attendings don't quite have down): as my family practice attending once told me, all he wanted me to be able to do was tell whether or not someone was sick. Because, truth be told, this initial highly subjective triage, is often the difference between life and death. Forget all the technological crap and ultra-hard core resuscitation techniques if you can't figure out if a kid is going to crump, or if an adult is gonna keel over. As a surgeon once told me, if you don't make this simple (though wildly complex) discernment without having to resort to reading a textbook, you might as well call it a night and work on your hamburger flipping skills.
And let me tell you, I certainly don't have this skill down, although, luckily, I have been erring on the side of caution. In other words, I tend to assume a patient is sicker than they appear if I can't be sure.
In a lot of ways, though, it's kind of simple. If the patient walks into your clinic (or emergency department), can talk, and can stand up and sit up without being distressed, he or she is probably not severely acutely ill. Also, you can't claim to be unable to breathe or choking if you can talk, and you can't be in severe pain if you've been going from clinic to clinic, looking for someone to write you a script for Vicodin. (Tip for Rush Limbaugh—I hear that some corrupt docs in Beverly Hills will shoot you up with Demerol for $10,000 a pop.) If you are conscious enough to be able to claim that it's an emergency, chances are, it's not an emergency. (Wow, this is turning into a guide for malingerers.) And remember, no ever died from pain. They might have died from the excessive sympathetic response the pain generated, but the pain itself can't kill you.
In fourth year, you actually try to do some of the assessment and plan, which, for the most part, you will have to lookup in some sort of textbook, or, ultimately, ask your attending. Although it is possible to memorize some of the easier workups, especially if you're a gunner. Myself, I think the only thing I feel competent enough to manage entirely by myself is asthma. (And only because I myself have asthma. Oh boy. Allergy and Immunology, here I come!) While conceptually simple, abdominal pain, chest pain, diarrhea, and fever still scare the shit out of me, because the differential is about a mile long for each of these entities, and some of those diagnoses can be really, really bad: small bowel obstruction or some even more acute surgical emergencies, massive myocardial infarction or pulmonary embolism, sepsis, cancer, or flesh-eating bacteria. The whacked out part is that it still obeys Bayes Theorem, and the ostensibly tautological dictum of "common things occur most commonly." So while you might be freaking out about a rupturing triple-A [abdomninal aortic aneurysm], chances are it might just be gas. If you're panicking about an M.I., you might find out it's just some muscle strain. If you fear enterohemorrhagic E. Coli or Shigella, it might just be Norwalk Agent or rotavirus or that liter of prune juice the kid decided to drink that afternoon. And if you agonize over TB or cancer or AIDS, it might just be normal hormonal fluctuation, the lady could very well be pregnant, or you might have just managed to measure the kid's temperature right after he had run a mile for P.E. immediately before coming to your office.
Tests will not help you. Never order a test if you don't know what you're looking for. Tests should only be for confirmation. Fact is, the thing that will help you the most about figuring out whether some guy has a massive M.I., or they're just having some reflux is your index of suspicion of how sick the guy is. Not to say that your index of suspicion can never be completely off track, seeing as it isn't based on any sort of evidence-based medicine. All it is is a pure gut instinct. And, while the gut does have as much neural tissue as the central nervous system does, you might want to temper your enteric instincts with some good old-fashioned reading. But at the same time, you probably don't want to inadvertantly catheterize someone who you later find out had been working out their pecs and was really just extraordinarily sore, only because you were paranoid and thought that they were, in fact, dying right before your eyes.
This is the reason why they call it an Art.
Anyway. Back to my main point. (Yes, I know. I have wandered quite a distance from the main path.)
The odd thing is that most of med school training as well as residency occur within a hospital setting, when in reality, most docs will practice primarily in an outpatient setting, whether clinic, urgent care, or E.D. Most people will not be working at a teaching program. And non-teaching hospitals are extremely different from teaching hospitals. For one thing, as a rule, nurses at non-teaching hospitals tend to be more hard-core. Because, if you think about it, they basically perform all the tasks that a resident would have to do at a teaching hospital. For example, while for legal and liability purposes, a house physician should probably be present during a code at a non-teaching hospital, most nurses would probably not be entirely uncomfortable with running the code themselves, especially the ICU nurses. They can manage a unit overnight without having to disturb the physician. For the most part, they may very well know more than the average resident, and certainly more than most medical students about the appropriate and realistic management of inpatients. So, be forewarned. When you start working in a non-teaching setting, you won't be able to hold the nurses in as much contempt as some of my obnoxious, arrogant classmates do at the teaching hospitals we rotate through. Because you will get your ass handed to you on a tray. I've heard of a surgeon who had been practicing for 15 years having to grovel because he pissed off an excellent veteran scrub nurse, and the administration demanded that he apologize or lose his privileges. I've heard of deliberate conspiracies by entire units of nurses to subtly sabotage docs who they think are obnoxious and arrogant, especially if they think they're corrupt. (Yeah, sure, there's optimal patient care to think about, but seriously, who does most of the in-patient care? In a teaching hospital, the residents definitely pull their weight, but in a non-teaching hospital, it's all on the nurses. And lest you scoff, remember that mortality rates are significantly higher at teaching hospitals than at non-teaching hospitals—although I suppose this probably has a lot to do with the fact that only really sick people end up in those high-end university tertiary and quaternary care centers.)
The worse thing, though, is that I actually like in-patient care, and if I see more than six out patients in a four hour period, I start getting cranky. Obviously, I'm either going to have to specialize, become a hospitalist, or just suck it up.
Anyway, that's all for now.
16:50 · permalink · add a comment
Wed, 11 Feb 2004 topthe system is broken (reprise)
another case study (some details embellished for completeness):
a 49 year old female presents with fatigue, unintentional weight loss, fevers, night sweats for several months. appetite is unchanged, the patient denies vegetative symptoms, exposure to tuberculosis, no GI symptoms—in otherwords, review of systems is essentially otherwise negative. physical exam is unremarkable, except for some skin looseness and white striae suggestive of rapid weight loss. cbc is within normal limits, with normal indices and differential. electrolytes and renal function are also normal. TSH is not suppressed. PPD negative. mammogram is done, yielding a radiolucency with irregular borders and microcalcifications, suggestive of malignancy. she is scheduled for a lumpectomy with axillary node dissection. several nodes are positive, and chemotherapy is started. the patient is referred to an institution that specializes in cancer treatment for an experimental (at the time) modality that involves high-dose chemotherapy and bone-marrow transplantation. MUGA scan was performed prior to starting the new chemotherapy regimen to see if the patient would be able to tolerate the procedure. because the patient belongs to an HMO, the specialist institution cannot be reimbursed if her ejection fraction is not more than 55%. MUGA scan yields an ejection fraction of 53%. at the time standard of care suggested a threshold of 50%. the patient does not undergo treatment, deteriorates over a course of four years, and then expires.
Now, I don't know the real clinical details of the case, but I imagine it at least approximates what happened to Zevrat Yedalian, who died at the age of 53 from breast cancer, driving her son to become a lawyer so that ten years after the diagnosis, he could sue Kaiser for denying authorization for treatment. in all fairness, Kaiser states that the patient had multiple co-morbidities that excluded her as a candidate for the treatment, which is likely, but obviously, my biases would tend to favor the patient and her family.
see, the problem is that I think that too many of these financially-motivated decisions are made by people who do not have sufficient medical training. A 2-hour seminar on common scenarios that a insurance adjuster/HMO administration might run into when interacting with physicians does not qualify anyone to deny treatment. Hell, if physicians, who have a minimum of seven years of training (four years of med school and a minimum of three years for residency), and likely more if they are hematologist/oncologists, have a hard time making decisions, how can some punk kid just out of business school cavalierly piss someone's life away?
let me tell you, I worked as a medical biller before I even started med school. now, I might have had more than a layman's knowledge of medicine because of growing up in a medical family, but, clearly, it's not like my knowledge base was very significant. and even with the limited fund of knowledge afforded by my dad's anecdotes and the ICD-9 manual, even I knew that the people I was arguing with on the other end who refused to pay the doctor I worked for had no idea what they were talking about. (Ever listen to pharm reps rave about the drugs they're selling? well, it's sort of like that—sorry C, I know there are exceptions!)
OK. I recognize that universal health care won't necessarily fix this situation. So I'll give you two more cases where I think it would.
a 14 year old female is referred to a nephrologist because of proteinuria, microscopic hematuria, and repeated episodes of pedal edema. no ascites, no upper extremity edema, no periorbital edema. occasional headaches, at least once a month, sometimes becoming so severe that the patient has to lie down and close her eyes, lasting for hours, not really relieved by Tylenol or NSAIDs. one episode also included unilateral blurring of vision which resolved spontaneously.
now, this was definitely an interesting case, but I then learn that the patient had already been followed by a nephrologist, had already had a renal biopsy at another hospital, and had been already diagnosed with membranoproliferative glomerulonephritis, but, unfortunately, her father's insurance changed, and she could no longer see the original nephrologist. In fact, she had been lost to follow up entirely for two years because of the various vagaries of health insurance. (don't you love pre-existing conditions? I am reminded of a scene from "The Simpsons," as Homer is filling out application forms for coverage: "Did I say heart attack? I meant to say brain hemorrhage!" anyway.)
so, now, we have to do the whole workup all over again, because we have no documentation, the patient's father has no idea how to obtain them, and in fact does not remember the name of the nephrologist. the workup includes a repeat renal biopsy (granted, given the time course, it would've been time to repeat a renal biopsy anyway, but, without the results of the first biopsy, the knowledge gained from a repeat biopsy would not be as ideal—there would be no baseline to compare it to.) and, the fun part is because of the patient's current insurance, we can't draw labs at our facility. they have to get them done at the lab specified by their HMO.
now, if you've ever worked in health care, you know how easily medical records disappear. they are likely written on self-destructing paper, which dissolves into dust the moment someone needs them. so I know that it can be sometimes dicey dealing with an outside institution. hell, sometimes they just don't want to give it to us. sometimes fifty copies of our medical information release request lie untended upon the lab's fax machine. sometimes the number given connects to a phone sex operator or psychic instead the lab's fax machine. This may be minor, and probably not significantly changed by universal health care, but, well, universal health care would allow us to draw the labs in the first place, circumventing any of the unreliability of relying on outside institutions.
so maybe this is quibbling.
but, you know, sometimes it can be important that you trust a particular laboratory. for example, if you are a pediatric endocrinologist, you want a laboratory that understands that you need a particular assay in order to measure LH and FSH levels (third-generation ICMA), which is quite different from what is normally ordered, particularly since this is more commonly ordered for adults than for kids. now, neither the more common assay nor this more specialized assay is particularly cheap, but you don't know how many outside institutions screw this up, performing the common, less sensitive assay, and yielding completely useless data. so, of course, the kid comes to the endocrinologist with worthless labs, wasting an office visit. the endocrinologist has to rewrite the orders. the kid has to get stuck again, and, hopefully, the right assay is performed, and then the kid has to come back to the office. now, besides the economic wastage, consider the amount of time this consumes. imagine if the kid has something serious, and this time is wasted. all of which could be avoided if you get to choose the lab you send the kid to, and you trust the lab to do the right thing.
so clearly, there is inefficiency and massive waste associated with redundant workups.
and a lot of wastage occurs when you have to deal with different entities who don't necessarily know the patient's history. as many attendings are wont to declaim, patients do not read the textbooks, and if you have to present and re-present to different physicians because of HMO rules and regulations, someone—from sheer probability—will make a mistake.
another case:
a patient who has no health insurance comes to a primary care clinic, brought by her family. the patient's mental status is somewhat altered, and she is not alert enough to answer questions, although she can ambulate with assistance, and responds to sound. vital signs show hypotension and tachycardia, and physical exam is remarkable for extreme pallor and diffuse abdominal pain. rectal exam is deferred, as the primary care physician recommends that the patient be taken to the nearest emergency room. initially, the patient and her family refuses; because of the lack of health insurance, they are reluctant to have to pay for emergent care. the PCP tries to educate them about EMTALA, and also suggests that going to a county facility would be another option as well. eventually, the patient needs to use the restroom and has a bowel movement. the family then departs, and it is unclear whether or not they make it to an emergency room, but the PCP examines the stool and notes that it is quite dark and tarry. the physician attempts to contact the family by cel phone, but there is no response.
now, if the patient and her family weren't uncomfortable about the possibility of massive financial expenditure, they might have gone to the right place for proper treatment, and maybe would not have been drawn to the primary care physician whom they know charges only $35 for an office visit. who knows what morbidity and mortality awaits this patient?
to continue my point in my last post about the need for universal health care, a lot of people defer medical care until the last possible moment. while, true, the most perfect health care coverage ever will do no good if the patient refuses to avail himself or herself of it, and refuses to adhere to treatment regimens, our current system certainly doesn't make things any easier. consider the scenario of the patient who developed leukemia after being lost to follow up. now, what is the most common presentation of leukemia? fatigue. c'mon. we all have fatigue. americans in general do not sleep enough, do not exercise enough, and eat horribly. there are a lot of (relatively) benign reasons for fatigue. and if a patient is working, will he/she really sacrifice their wages and spend money on an office visit (because there are still co-pays and deductibles to be dealt with, not to mention medication costs) just because they're feeling a little tired? so, if you don't have assiduous follow-up, chances are that the first time you present will be when your hematocrit is approaching single digits and you pass out at the mall and you have to be dragged in by ambulance. besides the simple physical risk, there is a significant financial expense to waiting for the last minute, made very tragic by the fact that it could've all been prevented if patients felt comfortable about going to the office and not worrying about how they're going to pay for it all. personal responsibility can only go so far. health is, in many intractable ways, a societal problem, and to deny this can lead to major and minor catastrophe. (for example, multi-drug resistant tuberculosis, hepatitis C, HIV, as well as the risks to the public at large of people passing out, seizing, stroking out, or having a heart attack while driving on the freeway.)
21:46 · permalink · add a comment
Sat, 07 Feb 2004 topthe system is broken
how's this for a case study:
a patient who should have been eligible for Medicare, but for some reason, wasn't being covered, came in to a primary care physician working in an underserved area for a healthy physical exam. history was unremarkable and exam was within normal limits, routine blood work was sent which showed no abnormalities, and the patient was lost to follow up. two years later, the PCP finds out through the patient's husband that she had recently died of leukemia. she had had no follow up care up until just recently, when she was forced to go to the county facility because of extreme weakness and fatigue. at county, she was diagnosed with advanced leukemia with a very poor prognosis, for which treatment options were extremely limited and unlikely to succeed. she quickly deteriorated and expired.
now, obviously leukemia can be fatal, regardless of what sort of health care you are receiving, especially given advanced age, but you've got to wonder, if she did have some kind of health care coverage and had been going regularly to a physician, would they have caught the leukemia in time to actually treat it?
now, imagine that it had been tuberculosis instead. how many thousands of people would've gotten infected in two years?
it doesn't even have to be infective to cause public harm. imagine if the patient had carotid stenosis. Or maybe aortic stenosis. Or CHF. anything that would cause hypoperfusion of the brain and cause the patient to black out. imagine if the patient is driving when a syncopal episode occurs. imagine if this happens on the freeway during rush hour traffic. or while the patient is driving 70 mph. or while the patient is driving by an elementary school around 2-3pm. or perhaps while driving down a street leading into a busy farmer's market.
now, since I'm aspiring to be an internist, I'm not optimistic. wait. let me be more specific. I'm not optimistic that the system is going to change anytime soon. while universal health care is something I truly believe in, I doubt it will ever happen during my career.
still, like S reminded me yesterday, you've got to practice as if the system were ideal. you can't skimp out just because you're not going to get paid. to be a good physician, you've got to practice as if universal health care were in place.
in reality, this will cause nothing but heartache, but you've got to aim high first, then let reality take you down level by level. because, even if you aim low, reality will still bring you down any way.
that's my theory.
but, despite my cynical veneer, I am, at heart, an optimist. so write a letter to your representative and your senator to pass universal health care.
Wed, 04 Feb 2004 topinterview season continued
this promises to be quite non-linear and exceedingly fragmented. bear with me or go look at goatse.cx.
the one thing I think I realized is that I can't stand the cold. having grown up in southern california, with ancestry from the philippines, this should not be surprising. (I am convinced that Filipinos are simply not meant to live in climes north of 35° latitude. I have one Filipino friend whose family is in Michigan and another whose family is in Illinois, and they both have raging season affective disorder.) thanks to some fluke of weather (many, many people swear that it is proof of global warming), all my winters in Chicagoland have been atypical (according to native Midwesterners who get annoyed whenever I complain about the cold.) this is not to mean that they haven't been cold. after all, for a southern californian, if the high temperature is less than 60° F, well it's time to break out the parkas, scarves, and mittens. but I have not had to endure more than one blizzard, and said blizzard only managed to shut down the entire metropolitan area for 24 hours. I haven't had to deal with unentombing my car from piles and piles of snow. I haven't had to try to stay alive in windchills approaching -80° F. In fact, for Chicago, I am told that I've seen very little snow. I am told I should be thankful that it hasn't snowed in May.
that said, it was still a profound culture shock. imagine my surprise when I came to realize that (1) Chicago has no spring season (it goes from winter to summer in around 5-7 days) (2) the high temperature rarely exceeds 50° F until around mid-May or so (3) it is not unusual (in fact it is the rule in the 5 years that I have been in the Midwest) for it to snow in April. often, late April.
I've also come to realize that it's not really the worst parts of winter that get me down so much. I mean, when it's December, January, or February, I think you kind of expect your life to be miserably cold. and, yes, I agree, snow is very pretty, and it really does get you in the mood for the holidays. but what kills me is March. In most other parts of the world, March is typically synonymous with Spring (and being a southern californian, spring used to mean 70° F highs to me) In Chicago, it does warm up in March. unfortunately, this only means that instead of snow, you tend to get freezing rain. let me tell you, there is no weather I despise more than freezing rain. so, really, I learned to understand that spring equinox means nothing in the Midwest, and I learned to endure March. it is really by April that I have gone insane. no matter how hard I try, I cannot comprehend the fact that it is April and the ground is still frozen and the high temperature has not crept above 50° F. while all my friends in california are sunning themselves on the beach and running around in shorts and t-shirts, I still have to put on a scarf and gloves. now, if you're from parts of the U.S. with the same or worse weather than Chicago, you probably have no idea what I'm talking about. but needless to say, April frequently leaves me in need of psychiatric help.
so. this is the background. thankfully, I did my Chicago interviews early on, so that I would actually consider matching to them. (because, despite the weather, Chicago is a great city, and the programs that I interviewed with were really good for the most part.) however, two weeks of interviewing in southern california, and then a day interviewing in Miami really made me realize how much I need sunlight to survive. still, after checking out NYC, since the weather is better there than in Chicago, my rank list has taken an interesting turn.
let me tell you, I have tried to avoid spending another winter in the Midwest. thankfully, I didn't notice the winter so much during my sub-I because I was always in the damned hospital. and then there were the holidays, and interviews in So Cal. so I didn't get back to the Midwest until the last week of January. oh boy.
one of the things I learned in my sojourn in the Midwest is that there are many different levels of cold. I had come in with the preconception that, once the temperature was below 30° F, the misery index was pretty much off the scale, and it didn't really matter what temperature was at that point. oh, was I wrong.
now, to many people, windchill factors sound like a load of crap. how are you really supposed to calculate what the wind makes it feel like. goodness knows that, empirically speaking, yes, a windy 30° F is a whole hell of a lot miserable than a calm 30° F. but, to actually quantify this difference in misery smacks a little of pseudoscience. but this is not my point.
what I learned that while 30° F is bad, 20° F is in fact worse, 10° F is awful, 0° F is horrific, and less than that is truly punishment from God.
the other thing I discovered is that it is usually warmer when it is snowing than when it is not. the most logical thing I've heard is that it's because of the cloud cover. there are even more loony theories about this empirical phenomenon, but I won't get into them here.
so. needless to say, in my week in Chicago, the high temperature was essentially in the single-digits. on the day I had to fly to NYC, I went outside in -2° F and had to walk to the L. needless to say, my snot froze. it's a really disturbing phenomenon, hard to explain. at this point, I realized that I am so done with winter.
the funny thing was, when I finally surfaced in Manhattan (downtown—I didn't realize that they had the trains running again at the World Trade Center site. that was eerie.) I got out in the 15° F weather and rejoiced. it was perceivably warmer. scary.
so when, on the day that I left, the temperature actually climbed above 32° F, I romped around (for all of ten minutes) without a jacket on, amazed at how warm it felt.
I might actually be able to bear 4 years in NYC. this probably has a lot more to do with the fact that I have two very good friends living there more than the weather.
still, right now, it's 46° F in L.A., and while it is definitely chilly, especially since my parents don't believe in turning on the heat, the sun is out, and in the end, that's really what I care about the most in terms of weather.
07:42 · permalink · add a comment
Mon, 02 Feb 2004 topit's over now
Two months, three timezones, the three largest cities in the U.S., four different climates with a 90° temperature difference, cold rain, warm rain, freezing rain, snow above 5,000 feet, 8 inches of snow at sea level, interviews with nine med/peds residency programs (I had applied to 12 and got invitations to them all, but I wasn't able to fit three of them in. Damn it, I'm never gonna see The Big Easy), three of which involved two-day interviews.
This came after a medicine subinternship that may very well be on par with if not rivalling my upcoming medicine ward months. We had two days off total for the entire month, at one point working sixteen days straight, having to come in on Thanksgiving (to just write notes, thank God.) Cross-cover was complete madness, with one subintern covering forty patients or so (for a total of eighty patients or so.) And the ancillary staff—well, the social workers and case managers were awesome, but the nurses and our team had something of a stormy relationship. And what would the month have been without a code—of course, all I managed to do was stand there with my mouth open, trying to stay out of the way—but I was the first one in the room. (Freaky, huh?) After the first week and a half, I started managing to leave just after sign-out, except for one of the last days, where I stayed almost three hours after sign-out on a pre-call day. For the most part, I thought I grooved pretty well with my senior. We had the same philosophy: get shit done, whether it meant chasing down consultants or tracking down films and enduring the undisguised disdain of some the radiologists, bugging the cards fellow until he finally got sick of me, reading my patients' echos first just to get me out of his hair. We were discharging machines—at one point I had gotten my own personal census to zero. It was a pretty fulfilling, but insanely tiring month.
But I don't really mean to complain (after all, internship will certainly be more wards months and nerve-wracking unit months as well.) I just wanted to chronicle that this has in fact been an intense three months. (Did I mention that, due to my ridiculousness, I ended up driving half-way across the country in order to go home—thankfully the weather held up, although that first day was quite touch-and-go with it raining and the temperature hovering around freezing, and that, because I'm not that great with long-term plans and commitments, I ended up only studying for three days for Step 2, and having to drive another 150 miles to sit for it?)
Needless to say, I am quite shot out.
I could sleep until internship starts.
More about the interview trail later. Maybe.
17:20 · permalink · add a comment
