Doctors are funny!

That is, except the tactless ones that ruin the Internal Medicine clerkship for 3rd year medical students. Anyway, I found this article online from The Journal of Family Practice (Howard J. Bennett, April 1995) and it amused me. It's about humor in the medical practice, and has wit throughout. Here's a couple of my favorites:

A surgeon, an internist, and a family physician go duck hunting.

The surgeon sees a duck, shouts "Duck!" and shoots it down.

The internist sees a duck, shouts "Duck! Rule out quail! Rule out pheasant!" and shoots it down.

The family physician sees a duck and blasts it out of the sky with a burst of machine-gun fire. As the tattered carcass falls to the ground, he remarks, "I don't know what the hell it was, but I sure got it!"

Rule out quail! Rule out pheasant! Hee. It's funny because it's true. I also like this:

To the Editor:

Last year, my husband, a pulmonary fellow, sent me a valentine; he thought that the cardiac system was receiving far too much attention on that day. I thought that your readers would enjoy the valentine.

A Pulmonologist's Valentine
Roses are red
Violets are blue
Without your lungs
Your blood would be too.

Here's the whole thing, if you're interested: Humor in the Medical Literature - Editorial

Geeeeeeeeez! I've been gone for awhile.

I have no excuse - just holidays, my birthday, and sickness. Did you know I've been sick on about 26 of the last 29 birthdays? It's kind of my trademark. You should see some of the pictures that I have from my birthdays when I was a wee tot - standing in front of a flickering Snoopy cake, looking unsure whether to blow on it or barf on it. Actually, in this day and age, you COULD see that picture. I'm at the apartment, though, and the picture's at home - I'll scan and add it later. I was so darn cute when I was a kid, I'd hate to deprive you of my cherubian face and my dark curls. (I'm not being vain - because while I was a cute kid, I'm not so cute anymore. So.)

What have I been doing, you ask? Let's see. I ushered in Christmas Eve. Then I ushered it out and ushered in Christmas. Then I ushered it out and ushered in my birthday (my 29th birthday - this is the one that I just keep celebrating the anniversary of, right?) and my pancreas reared it's ugly head even higher than normal. And then I got some sort of virus that came complete with lots of barfage, weird leg pain and twitching. That stayed around until New Year's Eve. Scott was very sweet through that whole viral crap - he came up to see me almost every day and was all attentive and stuff. Awww.

Then I started back to school on January 7th - I'm on my Family Practice rotation. So far, I really like it. It's soooooooo much better than my foray into Internal Medicine (I blame a lot of that debacle, though, on the fact that I was so sick and everyone was all, "How dare you be human!!!") This time, a whole different me showed up to the first day of the rotation. I am a lot more interested, responsible, and attentive when I don't feel like someone is stabbing me in the gut.

And I've watched Reign Over Me, Juno, and Enchanted. I'd recommend them all - especially Juno. I adore Michael Cera (is he too young to join my Geek Love Fake Boyfriend Brigade? I'll have to check.) And Ellen Page makes a great debut. It's funny, heartwarming, and just very darn good.

Oh, and I saw a toenail fungus yesterday. I itched the whole rest of the day. I know that Trichophyton (Trichophytons?) don't have legs and couldn't have jumped on me, but still. The mind is a powerful thing. Also, did you know that adults most commonly get toenail infestations by dermatophytes, which invade normal keratin? And that older adults (i.e., geriatric adults) most commonly get toenails infected with mold, which invade irregular keratin? I didn't either.

How to have your spirit crushed in 10 minutes or less

My last rotation, before I took "personal leave" for this rotation (which should have been my OBGYN) was Internal Medicine. I expected this to be difficult, because medical students know that the internists, especially general internists, are supposed to be the "thinkers". They have to know a little bit about everything. They have to know indications and contraindications for a whole slew of drugs, compared to the relatively minute number that psychiatrists master (don't get me wrong, psychiatrists know their drugs and they know them well). They have to know classic and not-so-classic presentations for a bunch of different conditions. They have to be able to work algorhithms in their head when the occasional zebra comes through the door. They interpret a ton of lab tests and radiology studies and they have to know when they should order more. In my Internal Medicine review books was a ton of information (the textbook itself, Cecil's Internal Medicine, was a workout to even carry.) And I was looking forward to learning it all, hoping to shine on this rotation since I had previously planned to try for a residency in Internal Medicine at the hospital that I was assigned to for my 4 weeks of inpatient service.

But.

I have pancreatitis. And if you've been reading my blog, you know I had a ton of problems with doctors right as the Internal Medicine rotation began, getting me off to a bad start with everyone - having to call in sick and looking like a slacker. My 4 weeks of outpatient service was first, so calling in wasn't a huge deal to the physician I would be working with for the day (it's not like I was part of a team yet - this was outpatient) but since the rotation was organized so smushedly (is that a word?), we only had a couple of days to spend on each specialty. So miss a day, miss pulmonary medicine. Or whatever. Anyway, it didn't exactly further my learning.

And then when my trusty GI doctor, the one who has cared for my pancreatic maladies (and those of my other family members) for YEARS, decided to be a giant buttface one day and tell me that he'd treat my pancreatitis, but he couldn't treat my pain. I'd have to go to a pain clinic for that. (Okay, there ARE no treatments for chronic hereditary pancreatitis except for pain management. If someone knows of an effective one, PLEASE, do tell.) I begged him to just treat me for the duration of this rotation, about six more weeks - to not make me try to find new doctors and switch my medications all around in the middle of this difficult rotation. Nope. He was committed to his buttfacedness. So I was forced to try to find new doctors and switch my medications all around in the middle of the difficult rotation.

I ended up finding a pretty great pain clinic and a good, compassionate doctor who treats me like a person, a patient in pain, instead of a junkie - but I had to go through a couple of bad doctors to get there. And I was in horrible pain for most of the rotation, operating at about 60% of my capabilities. All that severe pain, with no end in sight, eventually ended up making me seriously depressed, which didn't help matters at all.

And it REALLY, REALLY helps to be paired with a student who will actually work with you*. I wasn't, and I felt like one of the attending physicians that I worked with on inpatient was at times comparing the two of us (which they should not do.) Actually, I'll go ahead and stick a little story right here. I got to the hospital one Thursday morning by at least 6:30AM, in order to see my four patients and write a good SOAP note in their charts before 9:00AM prerounds. (And somewhere in there, I had to travel about 10 minutes to another hospital for a one-hour neurology conference, which was held at 8AM every Thursday morning. And I liked neuro, by the way.) Now, I had seen my first patient and was at least halfway through my progress note for her by the time my fellow student got to the hospital. I saw her head down the hall to the call room, where prerounds were held and where we would stash our stuff while rounding. She saw me, too. I saw two more patients and wrote notes on them, ran into the other 3rd year student a time or two as I rushed between floors, and (a little late, I'll admit) had to leave at about 7:55AM for neuro conference without seeing my 4th patient, who had had surgery and was in surgical ICU. I wasn't sure if we just breeze in and see her anyway - sometimes there are infection precautions and whatnot. So I thought I'd ask first. On my way down the hall to the main entrance, I saw my attending and I swear he seemed to glare at me. Maybe I was imagining things. Anyway.

I walked to my car (a meeeeeeellion miles away, because lowly medical students have to park a few yards past the moon at the hospital, so low on the totem pole are we) drove the 10 minutes to the other hospital, parked by the moon again, walked 18 miles to the building where neuro conference is held, went up the elevator, down the hall, and tried to enter as quietly as possible so I wouldn't disrupt ... my fellow Internal Medicine students, who were sitting there chatting. Huh? Note that the student who was on service with me was not there. All of the other students who was supposed to be there were there. There were no residents or interns, though, and no neurologist. So after a few minutes we decided that there must be no conference, and we dispersed back to our respective assignments.

I flew into the call room when I got back to the hospital, right at the beginning of prerounds. Late - huff, puff, huff, puff - drat! I explained to the team (attending, senior resident, other residents, interns, pharmacy resident, and the other third-year student) that I had been at the nonexistent neuro conference that no one told us didn't exist this week. The other student didn't say anything.

All the attendings have their own styles and quirks and such, and this particular attending would sometimes see patients on our list before prerounds, without the whole team. He happened to see two of my three patients, so I only had one to present, while the other student (who, remember, got to be at the hospital for an extra hour while I was being faked out) had seen four patients, none of which had already been seen and three of which happened to fall in a row on our patient list, so it seemed like she presented in her annoying "baby" voice forever. (She would present to the team - all guys except for me and the pharmacy resident - in this cutesy voice that sounds nothing like the way she really talks.)

I presented my one patient (although I did interject a little with my morning impressions when the attending brought up my other patients - an attempt to be more aggressive) - a patient that I had picked up the night before (when we weren't required to be there, mind you.) I checked the list and saw that he had just been admitted, so I went to his room and spent about 45 minutes getting a good history from his daughter-in-law, because the patient was a poor historian due to some head injuries. When we reached the end of the list, I asked the attending about my other patient - the one in surgical intensive care, and asked if I could still check on her. He seemed indignant and said that yes, we could - he had seen her that morning. I told him (and the team) that I would have checked on her this morning, but I was hurrying to get to the neuro conference that no one told me was canceled. The attending said, "[The other student] knew. [The other student] was here early this morning." Apparently, an intern had filled the other student in on the neuro cancellation and she hadn't bothered to page or call me to let me know (she did have both numbers.) Also, she knew I was there well before she was, but she didn't feel the need to point that out - she just let me look bad in front of the whole team. Wonderful. And one of my friends on the rotation told me later that the other student had told her during lunch that she had felt sorry for me when the attending pointed out in front of everyone that she knew about the conference and that she was there early that morning. Grrrr! I didn't need her pity, I needed her to speak up and say, "Actually, Kim was already here when I got here."

*If you're a third year (or fourth year) medical student and your modus operandi matches that of my fellow student - well, just don't. You make things twice as hard for the other students that you work with, you don't let them learn as much as they would otherwise, and you leave them with a bad impression of you. I think I'd rather work with almost anyone else in my class other than this girl. She was awful to be paired with.

All right, finally we get to my horrendous evaluation, the one that still has me questioning my choice of career even today. I went to the attending's office for a little "sit down" where I expected some constructive criticism (which I can take, by the way - and I realize this is a chip off of the iceberg of the yelling and the criticizing that I will get along the line), my strengths and weaknesses to be noted - that kind of thing. Instead, I was told that my first week with him was "difficult at best" and "a failure". The second week was "a little better" but "still not good". My presentations were just so-so. (For what it's worth, another attending in Medicine that I worked with for my first two years said that my presentations were excellent by the end of my 2nd year. Who to believe? Who knows.) My progress notes weren't good. My knowledge base wasn't there (isn't that what the USMLE Step One and the Internal Medicine miniboard test, both of which I passed by the grace of God? Hmmm.) He said that the assessment and plan portion of the note needed lots of work. (That was actually the only constructive part of the barrage of criticism that I could pick out. But here's the thing - I thought that the daily progress note should focus on the subjective and objective part - issues that had occurred overnight, how the patient was feeling this morning, that kind of thing. New complaints, resolution of old complaints, etc. Unless there was a new problem, I didn't see a need for the third year medical student to formulate a big detailed plan, when the patient had an attending, a chief resident, and an intern looking after him. Nevertheless, I tried to do my A/P better from then on - as redundant as I felt it was.) He wondered how I had made it this far, given the fact that I'm a terrible student and I suck so much. I told him that during the first two "classroom" years, that if I had a particularly painful day or days, missing class wasn't a big deal. And also, I was trying to find a new doctor and messing with my medications during most of this rotation. That didn't impress him much. He proceeded to make sure I didn't feel at all special - telling me about a resident that lost both parents suddenly yet continued to work, and how he lost a parent during his third year and pressed right on. At this point I was crying, out of frustration more than anything, because I was so tired of trying to get people to understand my illness and to understand that it's real. I felt like he was kicking me while I was down. At this point he said, "You cry a lot" which I'm not sure if that was an observation specific to me, or just a prediction for the clinical years and residency - like, "One will cry a lot." I don't know. My skin is getting thicker, though, believe it or not. Mom heard something on the radio the other day - Charles Swindoll, I think - about keeping a tender heart and a thick skin. Good advice for the physician and physician-in-training - have a tender heart for your patients and your loved ones, and a thick skin for superiors such as this attending. He suggested that I take some time off to get better. I said that I won't get better - it's in my genes and I'll always have it. But my talk with him turned out to be the proverbial straw that broke the camel's pancreas, and I decided to go ahead and take some personal leave - to get my medication straightened out and my pain under control (as much as possible, anyway) and to hopefully dig out of this super-deep depressing hole that I'd managed to fall in.

I'm still not out of the hole - and now I'm anxious about starting Family Medicine on January 7th, because I'm afraid it will be a repeat and I'll come up short, again. My talk with the attending is as fresh in my mind as it was that day - I replay it daily to myself and question, "Am I going to be a horrible doctor? How *have* I gotten this far?" I know it's the Lord holding me up because medicine is my calling, but is it? Did God send this attending to tell me to go down another path? I don't know. I'm praying about it. I'm still bumfuzzled, though, as to how my fellow student got rave reviews (I know she got "Honors" from one resident while I got only "Pass", because I happened to see it.) She may have talked more during rounds, but her answers were completely implausible sometimes (The attending asks, "This patient has just returned from a heart cath - why am I going to ask her about back pain?" to which the other student blurts, "Aortic dissection!" I knew that it WASN'T aortic dissection (that's a stupid answer - sorry) but I didn't know that it's to assess for retroperitoneal bleed. I do now, though, and won't forget it!), and I'm not the type to blurt answers just so I can allow everyone the privilege of hearing my fake cutesy voice. I want to think about the question first and try to give at least an educated guess, but she didn't give me time. She may have seemed a tad more enthusiastic than I did, but it wasn't much - I would have ran past her in the enthusiasm department had I felt well, because I love medicine and it continually interests me. She didn't spend more time at the hospital than I did. I often went in in the evening to pick up a couple of new patients, and spent time talking to them and reading about their illness, and to check on the patients I was already following. I am truly interested in the patients - I would wake up each morning wondering what kind of night they'd had. She may have felt up to doing more reading than I did - I'll freely admit that. Sometimes the pain wore me down to the point that I could do nothing but hit the couch and sleep for a couple of hours when my day was finished. But still, I fought it out until the end and I managed a B in the rotation. Thank You, Lord.

And then I heard from a very reliable source that the buzz in the Medicine department was, "Kim's performance is not up to par." That's just fantastic. I'd wanted to leave a good, lasting impression on the Medicine faculty & residents, and instead I did just the opposite. It makes me so sad.

Criticism of medical students from preceptors is a tough thing - preceptors either don't give it when it's necessary because they're afraid of hurting the student's feelings or getting a bad evaluation from that student. Or, they criticize TOO much, to the point where they've beaten the student down. I actually like constructive criticism and a discussion of strengths/weaknesses from preceptors/mentors/attendings/residents that I have worked with for a substantial amount of time - because geez, there is so much to learn and so many procedures and tactics to pick up, and knowing what I really need to focus on would be GREAT. Having someone bluntly go after my character, though? Not so helpful.

Good GRIEF. Sorry this is so long, for those of you who are still awake. It feels good to get it off of my chest, though. Any thoughts?

I may be climbing out of my pit

It's been a rough couple of months, y'all. I can barely talk about it without crying, because it was just so full of disappointment and sadness and pain, and it was like I was someone else entirely that I didn't even recognize nor did I like very much at all. (I do have horrible self-esteem and can't find much at all that's good about myself - except for Christ in my heart, of course, but that's Him, not me - but over the past couple of months, I *really* despised myself.) I'm sorry the posts have been so sparse lately, and I'm sorry that when I did post, that it was all about doctors and so on and so forth. Interestingly, my traffic has gone up quite a bit over the past 2 months. Figure that.

Anyway, I hope you, dear readers (I first typed "deer readers" - heh. Scott would be proud - that's what's on his mind at this time of year, too) don't have the idea that I'm some sort of drug-seeking pill-head. Instead, I'm a chronic pain patient struggling to learn to be a doctor, a good one - working 70-80 hour weeks in addition to trying to study in between, and also trying to spend time with my Scott, my family and friends, and some MUCH needed time at the Y. Oh, and sleeping, sometimes. It's hard to do that when it feels like someone is stabbing you in the gut, and pulling the knife around to your back. And then when you go to your doctor or to the ED for help, they instead berate you and you end up sobbing because of their jaded lack of compassion, it's discouraging.

Being in severe pain all the time, all the while being expected to perform in a superhuman manner (and getting bad evaluations when you don't - more on that later) and having more doors slammed in your face - it made me feel more hopeless and sad than I have felt in a long time. I didn't know if I was ever going to get help, or if this pain was going to become a part of my daily life. A Google search found a lot of information on depression resulting from chronic pain. I don't know what the answer is, fellow members of the healthcare system, but we have an underserved population of people here. I don't know how we weed out the true sufferers from the addicts and the dealers. But something needs to be done. And the way I heard other providers refer to patients requiring pain medication was less than encouraging.

I am doing all of the "alternative" stuff that the Interwebz recommends for pancreatitis - an antioxidant blend (the one I take is by Nature Made, with Vitamin A, 100% as Beta-Carotene - 10,000 IU, 200% RDA; Vitamin C: 250 mg, 417% RDA; Vitamin E: 200 IU, 667% RDA; Zinc: 7.5 mg, 50% RDA; Selenium: 15 mcg, 21% RDA; Copper: 1 mg, 50% RDA; Manganese: 1.5 mg, 75% RDA), and I'm also taking an additional selenium supplement, my trusty enzymes (amylase and lipase, aka Creon 10), and a couple of doses of Advil a day for anti-inflammatory properties.

I'm still hurting, though - I do have a new pain doc, and I'll talk about him later - I think I'm going to like him. He and his office staff are already a billion times kinder than the other Pain Clinic Which Shall Not Be Named.

I just didn't want you guys to think that I was an addict who was obsessed with getting my fix. Is that what you think? What DO you think? Let's have it, I can take it. It's why I have comments on my blog - I want to know what people think about what I write, and I appreciate and consider them all. Except the trolls, of course, which I just kick back under the bridge; and the potty-mouths, who I edit and *then* consider. :-)

I'm thinking that I should instead enter a profession in which you're allowed to be human - one where you can not know the answers to a few questions, or oversleep once or twice a year, or accidentally show up at the wrong place occasionally. One in which you can be sick, sad, or tired.

I don't know if I'm cut out for this, y'all - I really don't. I don't think I'm smart enough and I'm not good enough. And it really sucks, because I've been doing the very best that I can. It REALLY sucks. (Rather, *I* suck about 50% of the time, or so I've been told.) If you have a chronic illness, I wouldn't go into medicine.

On a more upbeat note than the crappy evaluation that I just got - I did find a doctor to manage my pancreatitis who seems to actually be sympathetic and kind. Hallelujah and praise the Lord for that! Although being forced to look for him in the middle of my internal medicine rotation really screwed me up.

Ugh. I'm tired of crying all the dang time.

And finally, a PSA - there was a car accident yesterday involving someone with the same name as mine, on the road that I travel to go home (home, home - not the apartment.) So Mom and Dad and I have been fielding a bunch of phone calls, emails, Facebook messages, and the like with people checking on me. That really makes me feel good, because I generally assume that no one cares if I'm alive or not. Especially since I'm the worst medical student that ever lived. But thanks to everyone who has inquired about me today - it made my day a little better!

Psychiatry Miniboard

Each rotation culminates in an NBME (National Board of Medical Examiners) miniboard exam, so that we can be somewhat standardized (you know, so people can't open up their own Billy Bob's School of Medicine and start churning out inadequate doctors.)

This is a useful outline that the NBME provides to help you figure out how much weight each subject carries on the exam for each discipline, and includes a few sample questions. Here's the psych miniboard outline:

• General Principles - 5-10%
• Promoting Health and Health Maintenance - 1-5%
• Understanding Mechanisms of Disease - 10-15%
• Mental disorders usually first diagnosed in infancy, childhood, or adolescence - 5-10%
• Substance-related disorders - 5-10%
• Schizophrenia and other psychotic disorders - 5-10%
• Mood disorders - 5-10%
• Anxiety disorders - 5-10%
• Somatoform disorders - 1-5%
• Other disorders/conditions - 5-10% (this probably includes personality disorders, because there was some of that)
• Applying Principles of Management - 20-25%
• Diseases of the Nervous System and Special Senses - 10-15%

The NBME also exists to be the bane of medical students' existence (I picture them all to look like Mr. Burns from the Simpsons - sitting around being animated, rubbing their palms together and going, "Yesssssss ...") The psychiatry miniboard, incidentally, wasn't bad at all. Other than reading a little throughout the rotation for our every-other-week quizzes, and doing further reading about a few major patients that I wrote up, I only studied hard(ish) for a day or two. I am a compulsive book-buyer, and I used Lange Psychiatry Q&A 9th edition, Blueprints Psychiatry, and First Aid for the Psychiatry Clerkship. I don't think there was anything that I couldn't answer by using these books, had I studied a little more (I looked up items that I didn't know later. As Christy says, I may be the only person on earth who studies more AFTER the exam that I do before it. Heh.)

Most rotations require a score at the 11th percentile to pass the exam (except OBGYN, which I think is 22nd percentile, and Family Medicine, which is somewhere around the 5th percentile because it includes surgery and OB questions, which are separate rotations that the student may or may not have had yet. The Family Medicine department gives its own exam in addition to the NBME one.)

So, I really liked psychiatry. Not just because the hours were really good or because the material wasn't beat-your-head-against-the-wall hard, but because it was interesting. I had a great group of fellow students to work with, too. I'm going to miss them when I start Internal Medicine tomorrow! I'm thinking of doing some time in psych as an elective next year, because no matter what your specialty is, you're going to deal with psychiatric patients and psychopharmacology. I would like to actually have a little extra training (seeing how I'm planning on a primary care residency) instead of just giving my patients whatever antidepressant that is written on my ink pen! (Not that primary care providers do that - I'm not insinuating that.)

No Internet For You!

My internet access has been screwed up all week, and Comcast is on my LIST, y'all. I'm currently in the library at the hospital waiting for a monsoon to pass over, so I thought I'd let my faithful reader(s?) know why I've been silent all week. And I really had lots that I wanted to say, too - I felt like writing. Oh well. I'm going home this weekend, where the Inter-webz abounds, and I will talk your ears off. Maybe.

Psych is going well, and I found out yesterday that my next rotation is Internal Medicine. Yay! With Christy! Yaaaaaaay! For Medicine, I've heard that we work in pairs, and I hope to goodness that I don't get paired with an undesirable person.

That's all for now.