On the wards .. finally!

It's finally here! I'm finally a wards resident!

We had a junior resident retreat a few weeks ago so that people could share the highs and lows of being promoted to resident. As I've had 6 weeks of elective and 2 weeks of vacation during the first 3 months of this year, my colleagues joked that they were trying to keep me away from the new interns! July sounds like it was pretty crazy in the hospital, so it's nice to have some interns who have been in the system for a few months when it's my first time being the team leader.

At the retreat, I confessed that I had been dreaming of my first day as wards resident and had been crafting my first day speech for months. My fellow residents chuckled at me, but based on my experiences from last year, I feel the resident sets the tone from the very beginning. My speech wasn't as articulate as I had imagined it would be, but I hit my main points:

1. I believe in the duty hours limits. Interns have to leave the hospital after 30 hours if not sooner!
2. We should function as a team. There's no "That's not my patient."
3. Training is about learning -- about diagnosis, disease management, and communication skills. Paperwork is something we have to learn how to do efficiently so we have time for the rest of our learning.

I was unleashed onto the wards a little over a week ago and met with the members of my team recently to see how things have been going. I've been trying so hard to be the kind of resident I would want--pitching in with orders and paperwork, making sure everyone gets food, and ensuring my team members go home and sleep. However, I wasn't sure if I was being the kind of resident they want.

Overall, it seems like things are going well. My attending said she couldn't tell it was my first time doing this, which plastered a big smile on my face. My interns appreciate our efficient rounding, and they feel well supported. However, they're both kind of worried about how much I've been eating and sleeping. And there it is. I'm totally exhausted. When I'm stressed out, my appetite goes down the tubes, so I haven't been eating right. Today is the first time I've spent more than 15 minutes with my husband in 3 days, and that's only because it's my day off. I've been so worried about my patients, students, and interns that I haven't been taking care of myself at all. Instead of helping everyone else in doing their jobs, I have to figure out a better way for me to do *my* job so that I can stay sane.

Despite my total exhaustion, I absolutely love my job.

I want to see a doctor, too!

I have a confession to make. I haven't seen my primary care doctor in almost two years. I'm relatively young and healthy, but I'm a believer in the annual visit. Those visits are not just for Pap smears, colonoscopies, and mammograms. It's just plain healthy to spend 30 minutes talking about your health with a doctor at least once a year. My primary care clinic is in a community health center, and I see a large percentage of young African American men. I usually don't run any tests, but we spend the majority of the time talking about safe sex, wearing seat belts, guns in the home, and developing good eating habits. (You won't believe how often young single guys eat fried chicken! Learn how to make a sandwich, guys!)

Anyway, so I haven't seen my doctor in a while. I actually made two appointments to see him last year. Making an appointment is half the battle since I have to remember to call during office hours and then find a day when both he and I are free. Sadly, I forgot to go to both appointments! I know I'm a bad patient. That's what happens when I schedule them on my one day off a week and then get so excited about sleeping in that I forget.

Instead, I try to monitor my health myself. I know what I'm supposed to be doing, but sometimes people, including doctors, need an authoritative voice to push them in the right direction. For the past two years without my doctor pushing me to take care of myself, I've turned to Oprah. I'm an avid Oprah watcher, and I really enjoy her medical shows. I'm sure I'm not the only American getting my health information from her gurus Drs. Mehmet Oz and Christiane Northrup. I even took Dr. Oz's Real Age Quiz. Despite my lack of exercise, I'm surprisingly one year younger than my real age, but I took the tips the website had to offer to heart. I went to a yoga class on my day off, and I've started flossing again as it was one of those habits that went by the wayside during intern year. I'm still working on the fruits and vegetables. Getting in five servings a day is hard work!

I'm a big fan of Dr. Oz although part of me feels strange about getting my medical information from a cardiac surgeon on television. So, I called my doctor's office today. His first appointment ins October 15th, but my first weekday off after that isn't until November. See you in three months, doc!

Google to the rescue!

Okay, I'll admit it: I use google to find medical information. I know I'm not the only one. Use of Google, Wikipedia, Emedicine, and other web sites is very common in the hospital among med students, residents, and attendings. I've seen you all using it! Usually I use google to confirm information I'm pretty sure I already know, but once in a while, I'm really not sure what's going on and give it a try.

Recently in the emergency room, I was pretty sure my patient had a viral gastroenteritis, but she had a black tongue. I had actually woken up with a black tongue last week, and it went away within a day. I didn't think any of it, but understandably, my patient really wanted to know why her tongue was black. So, I turned to google, and I found a wiki that linked to this:

The active ingredient in Pepto-Bismol contains bismuth. When a small amount of bismuth combines with trace amounts of sulfur in your saliva and gastrointestinal tract, a black-colored substance (bismuth sulfide) is formed. This discoloration is temporary and harmless. It can last several days after you stop taking Pepto-Bismol. Individual bowel habits, your age (the intestinal tract slows down with age), and the amount of the product taken all help to determine how long Pepto-Bismol is in your system.

I went back to the room and asked if she had any Pepto-Bismol recently, and she had! And I had some Pepto last week the night before my tongue turned black. Thanks, Google!

Nightfloat as therapist

As nightfloat, I was usually the last person interns saw at the end of their days and then the first person they saw in the morning. Being a social gal, I would usually ask, "How was your day?" More than once an intern started tearing up. Sometimes they would be angry, sad, frustrated ... the list goes on. Last year, I remember bottling up my emotions all day as I interviewed and assessed patients, tackled mounds of paperwork, and crammed some learning in, but when interns sat down to hand off their patients to me, sometimes it would all come out. That was fine with me as I didn't have anywhere to run to; I was working all night.

An end to the USMLE trilogy

I'm continuing on what seems to be an annual tradition of studying for some ridiculously expensive required standardized exam so that I can be a doctor. This year's test: USMLE Step 3.

Yes, I'm hunkering down in preparation for the last step in the USMLE trilogy. Don't worry, there's still the Internal Medicine boards! Plenty more testing to go in my lifetime! I like doing practice questions because reading prep books can be pretty dry. Step 3 covers a wide range of subjects, including surgery, obstetrics, and pediatrics. It feels like a long time since those third year clerkships, but after some studying, I know that you need some sterile saline, gauze, and ice to pack a severed finger for transport and that lesbians are at lower risk for cervical cancer than heterosexual women. My tip for Step 3 is that the answer is never "Quickly examine the patient in the parking lot." Got to love those ethical conundrums!

PPD negative and cavity-free!

The nice thing about being on nightfloat is that I have daytime hours free. I should be sleeping, but when else am I going to be able to run my errands?

I'm pretty sure intern year had a negative impact on my health. (Those hospital cafeteria chicken wings are pretty hard to resist.) However, it's nice to know that my teeth are still intact and that those N95 masks really do keep the tuberculosis away.

If only I could have gotten an appointment with my primary care physician! There's an 8-week wait for an appointment. Somehow I called my dentist, and I got an appointment within a week. I also called my mechanic and was able to bring my car in the next day. I have high hopes for change in our healthcare system not just because I'm a frustrated doctor; I'm also a frustrated patient.

Hello, PGY-2!

Now that I'm a PGY-2, I'm really looking forward to leading a team of interns and doing more teaching, but July 1st was a bit anticlimactic for me as I'm starting out on elective. In some ways, it seems wise to stay away from the inpatient wards this month. I've gone to visit some friends on the wards, and it seems like controlled chaos. My fellow PGY-2's are a little frustrated that their interns are not as efficient as we were, but we remember well how difficult the first few weeks were for us. Looking back, I was thankful to survive each day somewhat intact.

Although I'm not leading a team, new responsibilities abound everywhere I look now that I'm a resident.

• In the urgent care clinic, I'm now expected to see six patients a session instead of the four I saw just two months ago in the same clinic. I haven't become magically more efficient, but I'm quickly learning lest the nursing staff kill me for keeping them late!


• Next, I will be admitting patients overnight as the junior resident nightfloat. While there is a senior resident around if I have questions (in addition to fellows and attendings by phone), I'm largely expected to admit these patients on my own. I know it is something I am capable of, but I feel a bit like I'm swinging on a trapeze without a safety net.


• After a few weeks of nightfloat, I'll be in the emergency room, again without any interns to "boss" around. Instead, I will be running the "medical traumas" that come into the ER, such as overdoses and strokes. Yes, a patient will be rolling into a trauma room, and I will be yelling out orders!

This year will be an adventure, for sure. I'll keep you updated!

A Minute to Mourn

There's so much to write about, especially since I haven't written in over 3 months and today I officially am a PGY-2. However, I just wanted to take a minute to express something I'm feeling now -- the time missed with friends and family over the last year.

I remember when I was applying to residency programs and thinking about how each would affect my friends and family. My advisor said, "The people in your life will have to understand that for the next three years your needs, your training, your life will have to take priority." I know what she was trying to get at. For the last year, I have become less available, less flexible, less able to take care of the people in my life due to my training.

As I pour over my schedule for this coming year trying to find ways to be with my loved ones for weddings, birthdays, and holidays, I mourn all the ones I missed in the last year. I mourn the ones I will miss this year and next. I mourn all the unexpected twists and turns in the road they are experiencing without me.

Here comes the new blood!

People said February would be the worst, and it was. Even my CCU attending told me he remembers February of his intern year being a lowpoint in his life. Now that it's March, my spirits are magically improved. Is it because I was in the CCU in February pulling those fun 30-hour shifts? Is it because I am on my first vacation in eight months? Is it because spring is finally in sight? Or is it because yesterday was Match Day?

It seems that my Match Day was a lifetime ago, but alas, it was only last year! What a strange day! People were laughing and crying, but regardless of elation or misery, everyone wanted to drink as much alcohol as they could until their bodies said, "No more!" That's because they have spent the last nine months, the four years, or their entire lives waiting to find out what that envelope said.

What it means for me as an intern this year is that my replacements are on their way! They will shortly be signing contracts for the wild ride of intern year, and I will be moving on. Yes, the end of intern year is in sight! I know this means that I will be a resident in a few short months. It's a scary thought that I will try not to dwell on while soaking in the Caribbean sun.

ER vs everyone else: Where's the love?

I have to say that there is no love between the emergency room and the rest of the hospital. The main reason is because when the ER decides to admit patients, they are creating work for the residents on the wards and in the ICU. While sitting upstairs, it's easy to criticize the emergency room staff. We criticize them for admitting patients who look too well, and we criticize them for not doing more for the very sick. What I had not realized until working down in the ER was how difficult it can be to make judgment calls about a patient when they come in. Sure, the next morning when you know how the patient did, it's easy to say what should have been done. However, in the ER, sometimes there are so many patients in the waiting room, that you can't wait to see which way the patient is going to go. You make a clinical decision--you admit the patient to the hospital or you send them home with some good instructions on what should bring them back. And then you pray that you erred on the correct side.

Adventures in the emergency room

After working 30+ hour shifts in the CCU, I thought a 12-hour shift in the emergency room would be nothing. I was wrong.

First of all, I started with night shifts. There seems to be no easy way to switch your body over to being awake all night. I tried afternoon naps, but that didn't work. After three nights of work in the ER, I was finally able to sleep nine hours during the day. Too bad after four night shifts I now have to flip to doing day shifts!

The ER is an interesting place. I'm used to being upstairs where someone else has already decided that someone's problems are serious enough to be in the hospital. My biggest problem in the ER is adjusting my "bullshit meter". Who is in the ER for secondary gain? It's not the coziest place in the world, but it does offer a warm place to sleep and as many 4 oz containers of juice as you want. I've had people come in saying "I had a seizure" or "vomited up lots of bright red blood" or "I want to kill myself!" Individually any of these would be a serious complaint, and I quickly started to realize that they know if they say one or sometimes all of these things we can't kick them out the door for at least a few hours. Yes, the people who say these things are usually drunk and sleepy. However, they are also symptoms that are more likely in people who are drunk, and the fact that they're sleepy would normally be more concerning. Did they overdose? Try to kill themselves? Hit their head and lose consciousness? Probably not, but I worry and often rely on the judgment of those who have more experience.

The other thing I find interesting is that people come to the ER in the middle of the night for the most mundane things--sore throats, tooth pain, a cough that's been going on for a week. They know the wait is shorter if you come at 3 am. I know that this is a symptom of our broken healthcare system. I myself haven't seen my primary care doctor in two years because it's too darn hard to get an appointment. Sometimes the wait for a sick visit is a week. However, there are people who keep coming to the ER for the same complaint, and I ask them why they don't go see their primary care doctor in between visits. Usually, they say "I didn't think about going when I felt okay." It's probably silly of me to try to change the system one person at a time, but I sit down and tell them about the role of the primary care doctor. Despite the frustrations of the system, that person is the main coordinator of their health. If they continue to have complaints serious to them but not serious enough to be admitted to the hospital, they're not going to get fixed until something very bad happens. I might be imagining a light bulb going off in their head, but hopefully my pleas to go see their regular doctor are heard.

One more week until my first vacation in eight months! Can't wait!

Isn't it supposed to be a bad flu season?

People say February is when the interns hit rock bottom. Honestly, I'm so tired and burned out that I started wishing for the flu. Even if I had to stay home with rigors all day, I would get to see my husband and sleep more. I need a break! Despite my co-intern getting some terrible viral illness and my team treating two patients with influenza pneumonia, somehow I've escaped without a single sick day used this month. Oh well, a girl can dream.

an intern's worst nightmare ...

is falling asleep during rounds! I didn't even know it was my worst nightmare until it actually happened. To be fair, I was post-call without a wink of sleep and into the third hour of rounds. My attending called me out on it in front of everyone but was laughing. Whew!

A lifetime of learning, no kidding

I'm in the last week of my month-long outpatient rotation, and I had a long list of tasks to accomplish before entering the CCU next week. In addition to seeing friends and cleaning my apartment, I also wanted to slog through the tall pile of journals that has accumulated since last time I was on an outpatient month. Flipping through the January 17th issue of the New England Journal of Medicine, I was reminded how medicine is ever-changing. There is constant revision of therapies in addition to the social and political aspects of the medical field, and I need to keep up! Here are a few excerpts for those interested in what I've been reading.

I've had the opportunity to work with foreign medical graduates in the past, but this article really describes the sacrifices they make and the hoops they jump through in order to practice medicine in the Western world.

[Foreign medical graduates] must not only relearn the theory, which many of them first studied decades ago, but also master the social and behavioral nuances of being a doctor in the West. Some must do so while supporting themselves by driving taxis or picking fruit; others rely on meager personal savings or small government handouts. They are driven by the dream of becoming doctors again, but the reality can be a nightmare.

I need reminders like this so that I remember how lucky I am to do my crazy job everyday. I've heard about publication bias, but this article really lays the numbers out there.

Among 74 FDA-registered studies, 31%, accounting for 3449 study participants, were not published ... Studies viewed by the FDA as having negative or questionable results were, with 3 exceptions, either not published (22 studies) or published in a way that, in our opinion, conveyed a positive outcome (11 studies). According to the published literature, it appeared that 94% of the trials conducted were positive. By contrast, the FDA analysis showed that 51% were positive.

I haven't had an ethics course since I was a first-year medical student, but there are still many unanswered questions. When I read this case about cell lines derived from a patient's splenectomy specimen, I couldn't believe that the law wasn't more clear.

Under ancient Roman law, when agricultural crops were in the ground, they were owned by the landowner, but picked fruits and vegetables were owned by the farmer who worked the land. Trees taken from the land, however, belonged to the landowner. Is a removed spleen more like an ear of corn or an oak tree? ... Since the cells in human tissue are living and reproduce, perhaps they are more analogous to farm animals than to fruits or vegetables. The progeny of animals are the property of the mother's other. Is the cell line equivalent to [the patient's] "progeny"? Similar, an owner wrongfully deprived of livestock is owed the value of the eggs from converted chickens and milk from converted cows. Are [the patient's] immortal cells like chickens, and the protein products derived from them like eggs? The need to resort to cases that involve the ownership of corn, trees, cows, and eggs demonstrates the need to create modern rules that deal directly with the ownership and use of human tissue.

I remember in my medical school application essay I stated I wanted to enter medicine due the ever-change challenges the field encountered requiring a lifetime dedicated to learning. Boy, I don't think I knew what I was getting myself into!

Health Care in an Election Year

Our health care system is broken. I see examples of it everyday. People who can't afford their medications in the emergency room, hospital wards, or ICU due to poor control of their chronic medical problems. I am going into primary care praying that there will be meaningful change in the system that will allow me to take better care for my patients, but how does that translate into who to vote for? Well, I've been pouring over this site comparing the candidates' plans today. There are flaws in each of these plans as I really do believe in a single payer system, but they are all a step in the right direction. The devil will be in the details of how these plans are implemented. I'm still struggling with which candidate understands the deficiencies of the current system the best. I want my candidate to know which of the many parts of their plans to push for and which will have to be sacrificed as the plans are made into law.

I'm excited that I will be able to make it to the voting booth for my state's primary on Super Tuesday. I'll be post-call from the CCU and will go directly from the hospital to my polling station. I just don't know yet who to vote for.

Planning the future

As an intern, I take days one at a time. Once in a while, I'll actually look a few days ahead and plan to do something fun on my day off. However, I rarely look much further in the future. One of my medical students was bemoaning that the school was asking them to put in schedule requests for their rotations next year. It does seem difficult when you've only finished half a year to figure out what you want to do the next year, especially when these years are supposed to shape your future career. I told my medical student to suck it up because it doesn't end. I just submitted my schedule requests for the 2008-2009 year.

Filling out that form was mind boggling. When do I want to take vacation next year? I had to email all my engaged friends and ask if they were planning weddings before July 2009. When do I want to be in the ICU? Which ICU? What about electives? What do I want to be doing on July 1st? That's when I'm a brand new resident with brand new interns. I'll be a resident in less than six months!

Luckily, I'm on emergency coverage now with more than average free time. (Thank goodness my co-interns haven't been inflicted with that raging diarrhea that's going around.) So, I was actually able to step back and look at myself. I found that a lot of me is the same. I still want to spend vacations with my husband when he's on break from school. I'm still interested in outpatient medicine despite the copious amount of time I have spent in the hospital this year. And I'm still terrified that I will make a mistake and kill someone. Those were my guiding principles in filling out my requests.

What's changed about me? Less than I thought. While I'm on the wards or in the ICU, time is limited, so I don't get to indulge myself in my hobbies. Yes, spending time cooking or watching TV seems like an indulgence. (Luckily the writers' strike is making it easy for me to stay away from my television.) However, now that I have more free time, I have found happily that I am much the same person that I remember I was. And I'm relieved. Yes, I've changed as a clinician, but I'm still me.

Is the silence deafening?

So, it's been a long time since I've posted. I've started a bunch of entries, but in the end, I justified my long pause between posts by saying that the silence was saying a lot.

The greatest skill of an intern is the ability to prioritize. There's always lots to do each day. After rounding each morning, I think, "Should I write my notes? Go to morning report? Call my consults? Put in orders? Teach my medical students?" The ranking of priorities extends beyond the walls of the hospital, too. A few weeks ago, my car ran out of gas. That's never happened to me before, but time is limited. On my list of priorities, filling my car with gas was probably lower than it should have been. However, getting home to spend time with my husband is pretty high, and the gas would have been helpful in getting that task accomplished. I'm still learning how to prioritize, but on the list of priorities, this blog is somewhere below filling my car with gas.