IM:On my own

Holy Shit. I feel shell shocked. I can't quite explain how lost and insignificant i feel. How stupid. 

It was simple. I was on my own. I was told to pick a random patient. I was told to see them and write a note in the chart recommending my plan for patient care. I was told to get to as many as i could before rounds at 10. I had four hours. 

I couldn't even get one finished!  There were an insurmountable pile of co morbidities- so many people who have 5 and 6 and 10 and 15 serious illnesses. And one illness prevents you from treating the other and the other etc.  Its maddening and it takes hours to even understand the full scope. Then I am still at a loss.  

I went home today and feel like i'm choking on information I will never integrate. I am overwhelmed. I question whether I'm smart enough for this profession and wonder how in the hell anyone else is. Its an impossible job. One that the residents are expected to do in under 30 minutes. I could read a million pages and still not 

IM: Daily Dynamics

So i started Internal Medicine today. It wasn't nearly as bad as I'd heard--- knock on wood.  All of the residents and attendings are Indian. Not that its a problem except I can't understand them. They talk very quietly and mumble-- often switch from Hindi to English. But they answer my questions and seem nice enough.

I followed one of the residents to watch about 8 patients and then do rounds on 20. The social dynamics of the hospital are exactly and I mean exactly as portrayed on television. I was surprised that the stereotype turned out to be true. Rounds get announced over the intercom, but there are 4 IM teams so announcements are constantly being blared in the halls. When you finally find where you're supposed to go you give the attending approx 4 sentences to update them on your patient you just spent 1 hour checking up on.  He nods, mumbles in an indian accent and then goes to see the patient himself with his gaggle of white-coated students (pharmacy, medical, and nursing) and residents.  We crowd around the bed and he asks the patient the same questions you did only to get a better and more complete answer from the patient. The chief resident, also indian, tries to get the last word in edgewise and must always be at the attending's side, even if that means shoving you out of the way to do it. The attending, who must practice this, struts down the hall at freakin light speed with the chief resident trying not to run to keep up, shouting facts about the next patient.  It was ridiculously hilarious. The attending didn't actually ignore me or the other students and often told the chief resident to shut it with a derogatory finger. The questions he asked were ones I used to know once upon boards. Things like: What are the contraindications to metformin?  Why are we using coumadin here? What are the side effects of ACE inhibitors?  What are the complications of liver failure?   etc.

The attending also gave us assignments or topics to read about that night. It felt like every other sentence was "read about that." At the end of the day my palm sized notepad had 3 pages front and back dedicated to subjects to read. Let me tell you, none of them were simple readings. For example, he said to read about anemia. There are so many categories, subcategories, causes, etiologies, treatments, tests that you could write a 200 page book on it and still not know everything. I left the end of the day at 3 and couldn't wait to start reading on topics to hopefully know what was happening better than I did today.

I felt like an idiot constantly getting lost or going to wrong wing. I didn't know where charts were or how to use the computer. I was also mildly surprised at how little interaction the nurses actually want with you.  They didn't want to help me, they told me what I needed to know so i would go away.  Or at least that's the impression I got.  And it probably is frustrating because not only do students rotate in and out every month, but so do the residents. I didn't know that residents also have to do rotations except they are in charge of the patients.  And that's a scary notion, one i was vaguely comforted and horrified by. The first year intern girl I was with didn't know anything more than I did. She could do a good physical exam but then would summarize and look at me actually asking "What do you think I should do next?" or "What do you think that means?"   and I was all WHAT! I DON"T KNOW ANYTHING!

I thought for at least 2 cases she was just quizzing me, but when the attending asked her the same questions she admitted she didn't know.  So then I took her questions more seriously. There were several cases where she just took my word for it (what it said in the chart)  or wrote down my possible differentials and claimed them as her ideas (that actually made me kinda proud).   At the end of the day, despite my lack of confidence in her ability as a doctor, I asked to be with her tomorrow. It forces me to learn and think on my feet (i hope).

PSYCH: Final Thoughts

Well, first I have to apologize for not meeting my goal. I was unable to write every single day. I think its a combination of being completely exhausted and also maybe just a lack of interest after awhile. The repetitiveness of the day was less than thrilling after you saw one case of ADHD you saw them all. However, there is much to be said about seeing the physical difference in the kids through follow up and the true magic present in one single pill that can make (or break) some parent's life. 

I must admit i will be sad to see psych go, mostly because my preceptor (and his staff) was so awesome. Especially towards the end of the rotation I started feeling like I fit in. We had inside jokes and goofed around about crazy stalker patients who stalked one of the front ladies. We also teased the doctor. It was definitely a community, and I felt accepted. It is hard to leave that since I have heard bad things about my next rotation. I have to say that for those people out there who have never seen a "serious" gay man-- you have to meet my preceptor. His sexual orientation did not cause any awkwardness or impact at all on my experience. Actually, the saddest part was when his patients saw his wedding ring and asked about his wife. He always just said "she's fine" and ignored their deeper probing. There was one time when an older patient remarked that I was a "pretty one" and it was "too bad" that my preceptor was married. (talk about awkward on multiple levels). 

As to whether I think I could ever do psychiatry... I don't know. I suppose I could. It is a lot of follow up and control over who you see and when.  Since my preceptor doesn't do therapy (said he's not very good at it... too blunt) it was usually a day full of med checks and making sure there were no side effects. I told him I felt that he did a small amount of therapy in the med check meetings, telling parents the truth about what he thought or calling the kids on their bullshit. Its amazing what 15 minutes with him can do and... not do.   I can understand how there would be less of a burnout. It was hard to see a number of parents who just wanted you to give them a pill to fix their parenting skills. But then it was balanced by the parents who were so desperate to try anything and to see something work for them. 

In the end I would say its not off the list, but its not on the top, at least for me. I still want to excitement and variety that I haven't really found in psychiatry- outpatient psychiatry.   I was constantly talking to the preceptor about wanting to see rare disease or unmedicated patients for the experience. My preceptor appreciated me for that. He wrote me the best evaluation and honestly told me that I'm going to make an excellent physician. I'm glad to have his support.  I asked him to write me a letter of recommendation. And he agreed. I can already tell that its going to be one I'm going to use for every site, because despite our rocky start and the fact I was outshined by my fellow student-- he took the time to recognize my strengths. Maybe its because he's a psychiatrist, but i think he likes everyone. 

And I suppose I need a few words in here about the psych Shelf exam. It whipped my butt. I wasn't expecting so many neuro questions. I felt like it was all about vit b12 dementia and neurotransmitters. I got at least  3 questions on theophylline, an asthma medication. I used first aid for psych and tho it helped I should have studied a bit more out of my step 1 book. I hope I don't have to retake it, but at least if I do-- I can do significantly better on it. 

PSYCH: Assessments & worker's comp

so today wasn't a normal day in pscyh-land.  The doc was required to do a whole day of nothing but 1 hour worker's comp evaluations to decide for the courts if this person really deserved to be off work or not. Two evaluations by two different psychiatrists are required. These work ups are long and tedious. He uses the students to listen, take notes, and type up the notes in a particular, elongated psych SOAP.

PSYCH: Lame sauce

So, thursdays are always didactics. That means that its the weekly lectures. They are essentially the same kind of lectures I've been sitting through for the first two years. So i haven't escaped lectures yet. The sad thing is they really aren't of much use. Usually its a resident who gives them and they tend to be boring, but we do get a free breakfast. Since they are required, we don't go in to our regular rotation that morning. Once the lectures are done (around noon) we drive back out to his office.   Its sadly a big waste of time because we only see about 2-3 more patients. So not much to report.

What makes this even worse is the doc has been sick for several days so he's going to cancel all his patients tomorrow which means we get a day off. Although many students pray for this to happen, I'm sad because it means i see less and have less experience. Plus I hate not having anything to do. Since I don't know anyone, its even worse.

So no patients today after didactics, and no patients tomorrow either. Lame sauce.

PSYCH: Jail time

So jail wasn't what i thought it would be. I guess it wasn't what my doc thought it would be either.

So the first thing I learned is the difference between jail and prison. Jail is somewhere you go to wait to be sentenced or its somewhere you go for a short period of sentencing.  If you go to a prison it is long term and it means the court found you guilty of something pretty big. We went to jails.

The first one was way out in the middle of a corn field and it was full of guards and barbed wire. Every door frame you entered through had a glass door that had to be opened from the guard station. Only certain guard stations could open certain doors and as a rule, it was never the closest guard station. There was no control room that could open every door, so if you wanted to open all the doors you'd have to go from guard station to guard station- which is impossible unless there is a guard somewhere else to open your door. (confused yet?) Not to mention many doors came as pairs and if one door was open the other couldn't be unlocked until its match was closed. So moral of this story= if you are thinking of a zombie escape plan and need somewhere safe- don't go to the prison because chances are you won't make it out. Not because of the zombies but because of the complexity of the doors. And the inevitability that some person in a guard room will be eaten so they cannot open the door for the other group hence starvation.

The first jail we went to was clean. I was later told that certain less security inmates were offered '1 day free' if they helped tidy the jail facility. 1 day free means they get out 1 day earlier than sentenced. I always wondered how people got out of jail for 'good behavior.'  We didn't go to the inmates, but instead they came to us. We were put in the visit room and the guards let in one inmate at a time. The inmates wore different colored jumpers, they almost resembled scrubs (oh the irony). The color indicates what security level the inmate was on.  So Lime green was maximum security. Navy blue was lowest security.  There were 6 different levels.  The lowest allowed the inmates to go out into the community to work but they had to report back whenever they were not at work. So you could understand that the majority of the inmates who refused to come see us, were those who got to go to work.

Yes that's right, certain inmates can refuse to come see the psychiatrist. And frankly, he wishes all of them had that option because those who are required are generally pretty nasty. That said the majority of the  inmates were polite and even thankful that we were there. Not only were we a chance to get out of their cell but also somebody who would actually listen to them when they spoke. Guards are required not to. Most of the guards I ran into were rather portly and didn't instill a sense of security to me. However, the jail ran like clockwork. It was strict and well organized. The cells themselves, 'dorms' as the inmates called them, came in two varieties: normal and glass house.  the normal dorm was a bed, metal toilet, a small triple reenforced window about the size your fist, and a solid teal door with a lunch slot in it.  The glass house contained the same amount, but the doors and in many cases the walls were glass, so the guards could see what you were doing at all times. And let me tell you inmates and guards have absolutely no sense of privacy or shame at being naked. (more on that later)

We only got to go to the 'units' or cells when a patient was required to be seen and was too behaviorally challenged to be let out of their cell.  No guards accompanied us. We only saw one of them today.  He was rude in the way a teenage boy is rude to his mother for not giving him what he wanted. He slammed his hands on the table (aka picnic table screwed to the floor) and that was as violent as he got.  He wanted meds that we couldn't give him.

That's what they all want actually. Believe it or not most people in jail are depressed and report crying and wanting to be out within the first two-three weeks.  And nobody sleeps good.  They all want something to sleep.  Some even go as far as to say they want to be sedated so they don't have to feel 'guilty'.   I haven't decided if this is a con or not.  Many accept that we don't give sleeping meds, which is one of my docs rules for jail.  He says they are too habit forming, which is true. You can tell they aren't too happy about it, but very few are stupid enough to make any big thing out of it. Many actually pout like a three year old refusing to talk to you, or they just walk up to the door. Many also try to rationalize you into it, much like high schoolers did to your parents when they said no.  There were some that graciously accepted the explanation as well.

This jail had good record keeping and we saw probably 30-40 patients from 5:30-10:00 which is a pretty good stint. we get just a few minutes to assess each patient and determine if they are lying, seeking or real. I still haven't mastered this but the doc has got it down to a beautiful art.

The second jail is dirty and dungeon like. They have actual bars everywhere as opposed to glass. The cells are something i haven't ever seen. They have only 3 levels of security and they are the county jail. They have had several escape attempts and therefore the inmates MUST behave or else they don't get to see the doctor, their lawyer or anyone else. But i did get to see the medical cells. They were nothing but a large fuzzy blanket and a toilet. There is no bed, no windows, no nothing. These cells were about the size of a closet. They were more of what i was thinking of degrading. These inmates were not allowed outside or to the gym but once a week. The other jail gave their inmates outside time everyday.

This jail i saw many naked people just walking around the hallway with the guards. I guess the inmates refused clothes, which legally guards can't do anything about. Most patients in this jail were angry, young or immature. But nothing really exciting happened. The guards here were also alot angrier and more immature. One guard got pist and won't respond unless you use her first name only. She was also offended we didn't invite her to lunch.  The doctor told us that last week there was a fight but it was between the guards not the inmates, and worse, none of the guards were fired.

So anyway more stories later. :)

PSYCH: ugly truth

We had more disturbing cases today than I truely want to admit. I mean the majority of the troubled teens or the ADHD kids aren't that much of a psych problem as much of an environmental or behavoral problem. Things that need to be fixed with therapy rather than drugs. But they aren't evil. They are kids who have crappy parents or never learned right. Usually when they discover they can't push the doctor around they shape up. That's why the jail system works so good I am told, they get consistancy. My doc was telling me the other day that consistancy is required to deal with people in general so they know they can't walk all over you. And its proved over and over in his sessions. He has certain rules everyone must follow: 

• no meds until you've been sober (drugs or illicit drugs) for 6 weeks no exceptions
• no cussing, threats or raising your voice or you get kicked out and still have to pay for the session
• no video games or books in his office (for the kids) because we're talking about you and you need to know what we're saying (appts are only 15 minutes)
• the doc is under no obligation whatsoever to see you, and at any point he can kick you out of his office or refuse to see you. End of story.
• if you are late, you will not be seen that day and will be charged $50. You won't be able to schedule another appointment until you pay that money.

His rules apply to his staff (including us) as well. Can't be late and he doesn't have to put up with your crap. Its intimidating but nobody's been late yet. The doc was also telling us that some people are just evil and there was nothing their parents could do about it. These people realize at a young age that if they manipulate or are cruel they can get the things they want. Honestly, some don't recognize the line they cross and others do but cross it anyway. Today, we saw some of those cases.

One little girl came in with parents who wanted therapy, drugs and were willing to work on whatever. You could see their desperation. They only had two kids and the little boy was very well behaved. His sister however, was said to say or do things simply out of spite. Her father gave examples of how she at age 9 was screaming "i will kill myself if you don't..." blah blah. I guess she also steals things from other kids and doesn't respond to spanking.  The parents regale us with stories of manipulation that I would chalk up to teenage level and the whole time the little girl is sitting quietly in the chair in between her parents... GRINNING.  When the doc asks her why she does it, she shrugs and smiles bigger. It was probably one of the most disturbing things I've ever seen. I keep have this recurring thought that one day I'm going to be in my room in the dark and i'll turn around and see that little girl with a knife standing behind me with that little grin.  SERIOUSLY freaks me out.

There was also a little 7 year old boy who was brought in in a straight jacket. He had been brought from the hospital several days ago (who lent the straight jacket to the mom).  Apparently he stabbed someone in an attempt to kill them. The attempt was unsuccessful but the boy screams he's not sorry. He said he doesn't think they should live. He seemed a somewhat normal kid talking about toys and TV. He wouldn't talk to us about the incident and kept wanting to be let out of the straight jacket.  His mom was hysterical and begged us to do anything to fix him. I think she was afraid of him. It was hard for us to tell her there is no pill that would fix that, her little boy was just a bad person.

it wasn't all bad, though. There was a little girl,8, who told me I was pretty and wanted to sit on my lap the entire appointment, which is definately a first. It was cute. Until I realized she was totally playing me and actually stole the $20 I had in my pocket. I didn't notice until the girl had left. I felt incredibly embarrassed when I realized what had happened and how I hadn't noticed. The doc laughed at me and bought me lunch. 

PSYCH: the patients

Today went much like yesterday. It was even harder to get up at 4:00am than it was yesterday. I got home and I am bone tired. I have no idea how the doctor arrives everyday at 3:30am. But it went fast.

There were some very interesting cases. I have a few good stories to tell that will help you understand the typical cases and interesting people.

A typical girl
She is around 15 and covered in circle scars on her face and arms. They are 'bug bites'  that she 'picks' at. Her parents say she gets mad and scratches herself until she bleeds. She also had several episodes where she snapped tweezers in half and used them to cut her arms. Her parents were completely bewildered about what to do. She often threatened suicide and meds don't help. She says she's "not worried about scars." The doctor said to make her wear a thick rubber band on her wrist to replace the cutting. She still gets the pain and the parents get to keep their daughter with less permanent damage.

Mighty Mouse
She is as tall as me, weighs 94 pounds with red curly hair and acne. She is dainty, mousy and timid with crooked teeth. Her parents come in with her and they are overweight and stocky. Her mother has breasts below her elbows although her belly is not as proportional and very quiet. She is a new patient who has recently been hospitalized because she was "mad."  The father goes into stories about how the daughter gets raving mad and beats him with a broom handle. When asked what happens after that, he says he tries to walk away but she follows him.  He is convinced that this must be bipolar disorder to such an extreme point that he spends a huge amount of time trying to talk to doctor into it. The doctor immediately cuts him off and says no. The doctor explains there is a difference between blind bipolar rage and directed controlled rage. He says she acts out at home because its safe and she knows her parents won't do anything about it. He says that she is in complete control of her anger and she chooses what she does.  He got her to admit it by asking if she acts out in front of her friends or at school to which she immediately replied, "I don't get mad in public, that's just stupid- I don't wanna go to jail."  When the doctor suggested her parents call the police the next time she does it she gets upset and says "I"m not going to jail, I know what I need to do." which she keeps repeating. She gets very upset and threatens her father that he cannot even say that word to her or she will "get very upset." She begins to warn doctor he is making her upset.  She begins to cry and the father begins to quaver. Yes, quaver as in shake in his chair and he asks the doctor to stop saying the word.  The doctor actually laughs. He then yells at the father and says he should be ashamed for letting a little brat threaten him and get away with it. He yells and exchanges so many words he finally gets the father to freely admit he spoils her and wants to. He gets so frustrated that he just admitted it he goes silent for the rest of the lecture.  Then when asked to return the daughter replies "if i'm still here."

The Asperger's boys
Two college aged boys came in with their parents. Both were overweight and wore glasses. It was they way they walked maybe, or the way they fought over who was going to weigh more that I knew something about them was off. Not delayed, just socially not quite there. It was hyper rational, the kind you see on TV. The eldest was a little more lower functioning as far as intellegence went and he was more well behaved. But he kept saying "that's it I'm cut it out" without explaining the it.  The younger boy was so intellegent that his parents had put him in college. He had a very high IQ but he came back with a 2.0 GPA because he was "surprisingly social." Through the course of the interview, the younger kept rationalizing all his mistakes and admitting he had "complete lack of self control" as well as going off on a tangent about how he was "spoiled" by his mother, who also admitted it. It was discovered that she gave him $200/week spending money so he could have fun in college. Even though the importance of studying was discussed with everyone in agreement, the mother abashedly admitted that she couldn't stop giving him the spending money. She knew she shouldn't but she didn't want him to stop hanging out with his friends (who were probably only hanging out with him for the money). It became chaotic when the mother keeps talking and admitting she's a guilty parent for birthing two asperger's boys, while the dad is trying to comfort her, while the youngest is rationalizing over everyone, while the eldest puts his hands in his ears and rocks back and forth saying "everyone's crazy."  It was a new experience because these boys were true asperger's and truely smarter than me. It was an odd feeling to have to think that this disease is simply a social inadequacy rather than one of the mind.  It also convinced me that a certain pathology teacher of mine doesn't have true asperger's.

more cases later...

PSYCH: Day 1

As expected: Most of this job is actually about smoozing the ladies at the front. They are fun and talk about car crashes, dates, kids, husbands and restaurants- pretty much all the subjects I know nothing about. I continue to feel minorly socially retarded because I never seem to be making the right comments or laughing at the right jokes. There are two other students in the office, one a charming male who got on everyone's good side with his laid back yet secretly brilliant personality. The other is a girl who is leaving tomorrow, but the doctor constantly teases her and refers to her as 'exceptional'.  I get the distinct impression I'm a bit too gunnerish and maybe overexcited-- which was expected. I just hoped I would be able to make a comeback a little quicker than this.

Unexpected:  My preceptor primarily works with kids  (minus jail days). We see a patient every 15 minutes and he is a stickler for being on time. He is a no-nonsense person who has no problem with telling parents how to do their job and that they are awful (if they are). He also tells kids exactly what they don't want to hear but need to. This makes me inherantly respect the guy and it makes the fact that I am an 'average' student a little harder to bear.


About the patients:
Troubled teens with parents who let them get away with too much or ADHD kids are the primary part of his practice. Several other cases were a survivor of a car crash when she was an infant and as a result she is now brain damaged. Another was a man who does and has always believed he was a woman. A case of PTSD from an old veteran. Thus far there haven't been any drug seekers, at least not that I have seen. At least thus far, I feel like its alot of problem parents who pass their problems on to their kids--whether its genetic or by example.

The good news is I'm writing progress notes and next week we ar supposed to start writing prescriptions. I'm actually kinda excited about it. More soon.

Postponed.

Because the jail has not yet cleared my papers, I was not able to accompany my preceptor to the jail today. Instead, I was asked to take the day off. So I slept in, checked out the medical library, and went to the grocery store.  Lame. Til tomorrow.