All the new 3rd year med students started today and it helped me realize just how far I've come. Though I've had my doubts, I did learn a lot over the past year, mainly about functioning as part of the hospital team and caring for patients. If I had to take Step 1 right now it would be bad news (and I have Step 2 fast approaching...). Anyways, it felt good being able to help oriented the 3rd year students and it definitely helped that I've been on the pediatric cardiology rotation since the beginning of June. It's been good...lots of babies with congenital heart disease including way more hypoplastic left heart disease then seems statistically possible (though I think they just need such complex surgeries--imagine basically completely reconfiguring a heart the size of a small strawberry in the Norwood procedure--that they need to spend more time in the hospital than most kids). I also took care of a girl with rheumatic heart disease which apparently is good preparation for my trip to Kenya. I'm maybe getting better at reading EKGs and listening to heart sounds, though I have a long way to go. I really like my team and I feel I can actually be useful which is always nice.
I had a few crazy days last week with little sleep. I've started working as an extern in the St. Francis ER so Thursday I did my full day of peds cardiology starting at 7am (including a presentation to high school students about med school)...then right after work I drove to St. Francis and worked over night in the ER (fortunately they let me go to sleep at 2 am and just sleep the rest of my time there-nice to make $15 an hour not doing anything). Then I had to come back and work all day Friday since technically I wasn't post call, it just felt that way. The next morning I got up at volunteered at this PBS Kids in the Park event where we helped preschoolers do check-ups on stuffed animals. Good times. Thinking about intern year and keeping that schedule all the time is a little scary. I took pediatrics call yesterday though I couldn't stay over night. This year my goal is really to focus on preparing myself to feel semi-competent as an intern. Scary. We'll see how it goes...
Thursday, June 17, 2010
Tuesday, May 18, 2010
Med Students Anonymous
2.5 days left till my psych rotation (and 3rd year!) is over! It can't come soon enough...I think I'm about to become a basket case...most likely I'm experiencing Generalized Anxiety Disorder or Psychosis NOS. Just kidding...I think. It's definitely time for a vacation. A road trip to Yellowstone is exactly what I need right now.
Still, I've enjoyed psych (though I won't miss having to use a key to get through every single door...the joys of a locked ward). It has unquestionably produced some of the best stories of the year and I've seen people come in completely unhinged and pull it together over night with the help of some meds (or maybe they're just sobering up). I also got to see Electroconvulsive Therapy which was nothing like One Flew Over the Cuckoo's Nest since the patients were anesthetized and none were as energetic as Jack Nicholson to begin with. There have been a few patients who are severely over medicated but that's way more reversible than a lobotomy.
Substance abuse has been a major issue with a lot of the patients and from the way they talk it seems like you can find heroin on every street corner. Procuring drugs is definitely outside my skill set but I don't think it would be professional for me to ask them for details. As part of the rotation we had to attend both an AA Meeting (yes they really did say the serenity prayer and recite the 12 steps...plus I got to say "Hi, my name is Lianna and I'm a medical student"). People's willingness to discuss their problems openly was incredibly impressive and I can definitely understand how hearing stories from people who are going through the same thing can be really beneficial. Having some goody two shoes doctor tell you to quit smoking crack probably doesn't cut it. Unfortunately only 30% of people maintain sobriety through AA, but it's still better than 5% of people who try to quit drinking by themselves. Bad news. I think med students could benefit from frequent meetings to share our horror stories and stresses. I can't believe the school year is almost over. In less than a year I'll be a doctor!
Still, I've enjoyed psych (though I won't miss having to use a key to get through every single door...the joys of a locked ward). It has unquestionably produced some of the best stories of the year and I've seen people come in completely unhinged and pull it together over night with the help of some meds (or maybe they're just sobering up). I also got to see Electroconvulsive Therapy which was nothing like One Flew Over the Cuckoo's Nest since the patients were anesthetized and none were as energetic as Jack Nicholson to begin with. There have been a few patients who are severely over medicated but that's way more reversible than a lobotomy.
Substance abuse has been a major issue with a lot of the patients and from the way they talk it seems like you can find heroin on every street corner. Procuring drugs is definitely outside my skill set but I don't think it would be professional for me to ask them for details. As part of the rotation we had to attend both an AA Meeting (yes they really did say the serenity prayer and recite the 12 steps...plus I got to say "Hi, my name is Lianna and I'm a medical student"). People's willingness to discuss their problems openly was incredibly impressive and I can definitely understand how hearing stories from people who are going through the same thing can be really beneficial. Having some goody two shoes doctor tell you to quit smoking crack probably doesn't cut it. Unfortunately only 30% of people maintain sobriety through AA, but it's still better than 5% of people who try to quit drinking by themselves. Bad news. I think med students could benefit from frequent meetings to share our horror stories and stresses. I can't believe the school year is almost over. In less than a year I'll be a doctor!
Monday, May 3, 2010
It's All In Your Head Part 2
Stomping out mental illness has been quite the trip. The past week on the psych ward has been a lot more work than I imagined, but at least it's engaging and I actually feel like I'm part of the team. The patients keep things interesting...the guy who collects dead squirrels (and carries their rotting corpses around with him) because he thinks they're talking to him), the guy who thinks he's Satan, the lady who stabbed herself with a kitchen knife when her boyfriend said he was leaving her (she was actually the normal one of the bunch). I actually enjoy talking to them, trying to figure out how they ended up in this position, trying to get them back on track.
Of course that raises the question of what is crazy anyway. I mean, in some of the patients you instantly know they're out of whack, but in the majority they actually seem pretty normal until you ask them if they've heard any voices recently. I got to go to court to watch a commitment hearing and our patient really came across as totally sane on the stand, it was only testimony from her mom about her hoarding tendencies that got her committed. Then there's the idealistic kid who recently dropped out of college, smokes pot, and thinks that there's a government conspiracy supporting the corn industry resulting in high fructose corn syrup in all of our food products. Not wanting to participate in a dysfunctional society is not necessarily crazy. Plus, most of his views are pretty much identical to those of some of my friends. Go figure.
I've always been leery of psych meds...but they definitely get results. If you've got mild depression a little psychotherapy might go a long way, but for bipolar mania or schizophrenia it's hard to argue that just talking about it will make everything better. Still just talking about things can be incredibly beneficial and perhaps it doesn't happen enough. What about Mind Over Meds?
Of course that raises the question of what is crazy anyway. I mean, in some of the patients you instantly know they're out of whack, but in the majority they actually seem pretty normal until you ask them if they've heard any voices recently. I got to go to court to watch a commitment hearing and our patient really came across as totally sane on the stand, it was only testimony from her mom about her hoarding tendencies that got her committed. Then there's the idealistic kid who recently dropped out of college, smokes pot, and thinks that there's a government conspiracy supporting the corn industry resulting in high fructose corn syrup in all of our food products. Not wanting to participate in a dysfunctional society is not necessarily crazy. Plus, most of his views are pretty much identical to those of some of my friends. Go figure.
I've always been leery of psych meds...but they definitely get results. If you've got mild depression a little psychotherapy might go a long way, but for bipolar mania or schizophrenia it's hard to argue that just talking about it will make everything better. Still just talking about things can be incredibly beneficial and perhaps it doesn't happen enough. What about Mind Over Meds?
Sunday, April 25, 2010
It's All In Your Head
Somehow my neuro rotation is already over. In theory neurology is really cool...but in practice it's one of the last things I would want to do. I love neuroscience. I love the brain. While I'm not wild about dissecting mouse neurons (and killing mama rats), figuring out how the mind works is the next frontier. So cool. I would love to stick people in fMRI machines all day and see what happens (aside from them getting really claustrophobic) just like in Why We Love.
So what don't I love about neuro? For the interesting diseases such as ALS, Muscular Dystrophy, Alzheimer's and Parkinson's there's only so much (or nothing at all) we can do to treat patients right now. While the doctors can provide support and guidance, really they're just there to watch you slowly die. You can give people who have strokes TPA if they get to the hospital in time, but if they don't you just verify that they had a stroke and send them off to rehab. And don't get me started with all of the chronic pain/headache patients. I have total respect for doctors who manage that sort of amorphous complaint, because the pain certainly can be real, but not necessarily physiologic. Sure there are some great seizure medications out there, but then you have to differentiate the real from the "ma'am, that was not a seizure, that was a dance move". Oh how I love pseudoseizures, excuse me, "non-epileptic seizures". Every day of the past two weeks I kind of felt like I would have one myself if I didn't get out soon.
In other words, I hope to continue learning as much as I can about the brain for my own enlightenment. What's not to love about Oliver Sacks and "The Man Who Mistook His Wife for a Hat"? Plus Eric Kandel's amazing autobiography "In Search of Memory", apparently now also a documentary, was one of the most inspiring books about research I've ever read. And then we have the story of our very own Jill Bolte Taylor...check out her priceless "Brain Bank Song" she sang on Oprah's Soul Series (Part 4 Minute 25:15). I could sure use some inner peace right now, but I'd like to pass on the hemorrhage.
So what don't I love about neuro? For the interesting diseases such as ALS, Muscular Dystrophy, Alzheimer's and Parkinson's there's only so much (or nothing at all) we can do to treat patients right now. While the doctors can provide support and guidance, really they're just there to watch you slowly die. You can give people who have strokes TPA if they get to the hospital in time, but if they don't you just verify that they had a stroke and send them off to rehab. And don't get me started with all of the chronic pain/headache patients. I have total respect for doctors who manage that sort of amorphous complaint, because the pain certainly can be real, but not necessarily physiologic. Sure there are some great seizure medications out there, but then you have to differentiate the real from the "ma'am, that was not a seizure, that was a dance move". Oh how I love pseudoseizures, excuse me, "non-epileptic seizures". Every day of the past two weeks I kind of felt like I would have one myself if I didn't get out soon.
In other words, I hope to continue learning as much as I can about the brain for my own enlightenment. What's not to love about Oliver Sacks and "The Man Who Mistook His Wife for a Hat"? Plus Eric Kandel's amazing autobiography "In Search of Memory", apparently now also a documentary, was one of the most inspiring books about research I've ever read. And then we have the story of our very own Jill Bolte Taylor...check out her priceless "Brain Bank Song" she sang on Oprah's Soul Series (Part 4 Minute 25:15). I could sure use some inner peace right now, but I'd like to pass on the hemorrhage.
Tuesday, March 30, 2010
Salvage
Generally speaking it's never a good sign if the word salvage is associated with your medical treatment. Whether salvaging a limb, salvaging heart muscle, or using salvage chemotherapy, things can only be kind of desperate and the outlook can only go from bad to worse. In hematology, salvage chemo is usually not well established, there aren't many controlled trials and even fewer good outcomes. Not saying it never works...just that working is usually defined in terms of extra months or weeks of life, rarely anything close to a cure. And sometimes just stopping and making the most of what's left is the best move. Our patient with fungal sepsis decided to marry her boyfriend and spend the last weeks of her life at home. I find it hard to fathom that turning point, where you're ready to give up on life, but at the same time rationally I think it's a completely reasonable decision when all remotely useful treatments have been exhausted. Grey's Anatomy actually had a really moving scene in the most recent episode, Suicide is Painless. A patient with terminal lung cancer describes how hope can be extremely damaging when you are ready to die. She's living in pain and there's no chance of a good treatment or cure...she wants physician assisted suicide and is happy with that choice. However, the thought of what if (what if there was a new cure, what if something had been missed and she's not really terminal) keeps her from being completely at peace with her decision, even when there really, truly is no hope. Insightful. There was also some annoying talk about Whoville...which as much as I love the Grinch Who Stole Christmas seems like a desperate attempt to start a catch phrase. I mean, SERIOUSLY. I miss the glory days of Grey's.
Speaking of salvaging. I spent the past week trying to salvage what remained of my medicine rotation. I definitely suffered for serious burnout right around the time I would normally be having spring break instead of working 13 days in a row. Now it's on to neurology which has it's own depressing set of problems and even less effective treatments. But at least it's spring!
Speaking of salvaging. I spent the past week trying to salvage what remained of my medicine rotation. I definitely suffered for serious burnout right around the time I would normally be having spring break instead of working 13 days in a row. Now it's on to neurology which has it's own depressing set of problems and even less effective treatments. But at least it's spring!
Wednesday, March 10, 2010
Healing Hands
Hematology has been a different world from life at the VA. The new cancer center is amazingly nice...big, well decorated rooms, floor to ceiling windows, fake hard wood floors, a meditation room, a courtyard with a giant sculpture, bamboo, a staff sanctuary...it really does create a good atmosphere. Never underestimate the importance of beautiful pictures when you feel like hell. The rotation itself has been a little awkward, even the resident doesn't really operate with anything like autonomy, which I guess is how it has to be in a super subspecialized acute care setting. In one week I've seen lots of AML and multiple myeloma...along with ALL, CLL, ITP and some lymphoma. It's been interesting to see how adult oncology differs from pediatric oncology...different diseases (I'm actually glad I'm doing hematology not oncology since most pediatric cancers are leukemias), slightly different chemo regimens, and those poor adults have to be awake during bone marrow biopsies (I don't think I truly appreciated how painful they are). The tranquil setting definitely helps.
Today was an interesting day. I was grilled by my attending, Dr. F, over pulmonary and cardiovascular physical exam findings. Scary but actually super helpful...when I can get over feeling like an idiot, I definitely learn the most when doctors ask questions and really teach. I could use more of it. Then I got to observe Dr. F in his bone marrow transplant clinic and see him grilled by a similarly type-A patient who wanted to know his prognosis...not just statistics but a specific number of years...an impossible question. Dr. F's response "Only God really knows, and he hasn't told me". I could do without the God part, but I think it captures the degree to which outcomes can be very patient specific and hard to pin down despite all the risk stratification. Control what you can control because so much is out of your hands. One of our patients, a woman in her 20s with refractory AML, has been growing fungus in her blood and now it's spread to her skin despite anti-fungal therapy. She has no white count and she can't fight the infection until she has a white count which probably won't happen for several weeks, if she even lasts that long. No one has told her yet.
Speaking of God, today the director of palliative care and a hospital chaplain performed a blessing of the hands ceremony for all the doctors and nurses caring for cancer patients. It was very symbolic and beautiful...they personally washed each of our hands and anointed them with oil (?!?). I love the idea of the ceremony, "blessed be these hands that have touched life, and felt pain, and embraced with compassion" but it was also way too non-secular/O Holy God, for me. I'll happily swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, but I'm not about to join STO.
Today was an interesting day. I was grilled by my attending, Dr. F, over pulmonary and cardiovascular physical exam findings. Scary but actually super helpful...when I can get over feeling like an idiot, I definitely learn the most when doctors ask questions and really teach. I could use more of it. Then I got to observe Dr. F in his bone marrow transplant clinic and see him grilled by a similarly type-A patient who wanted to know his prognosis...not just statistics but a specific number of years...an impossible question. Dr. F's response "Only God really knows, and he hasn't told me". I could do without the God part, but I think it captures the degree to which outcomes can be very patient specific and hard to pin down despite all the risk stratification. Control what you can control because so much is out of your hands. One of our patients, a woman in her 20s with refractory AML, has been growing fungus in her blood and now it's spread to her skin despite anti-fungal therapy. She has no white count and she can't fight the infection until she has a white count which probably won't happen for several weeks, if she even lasts that long. No one has told her yet.
Speaking of God, today the director of palliative care and a hospital chaplain performed a blessing of the hands ceremony for all the doctors and nurses caring for cancer patients. It was very symbolic and beautiful...they personally washed each of our hands and anointed them with oil (?!?). I love the idea of the ceremony, "blessed be these hands that have touched life, and felt pain, and embraced with compassion" but it was also way too non-secular/O Holy God, for me. I'll happily swear by Apollo, the healer, Asclepius, Hygieia, and Panacea, but I'm not about to join STO.
Monday, March 1, 2010
Good Medicine
Every morning this past month on the way to the VA I walked past the remains of an old hospital being torn down. Quite impressive actually, watching a building get ripped apart (though who knows how many toxins I inhaled), but also kind of depressing. And that's how I felt with my month at the VA...one chronic health problem after another slowly destroying these patients until something like cancer or an MI comes along and really knocks them down. There's not really a good endpoint...sure you can try to fix the acute situation, but death is always there somewhere. Plus I felt like every single patient had diabetes, hypertension, chronic kidney disease, hyperlipidemia and BPH. Good grief! They could be my dad!
Don't get me wrong, I actually really enjoyed the month...I liked talking to the veterans, I liked having a little more autonomy (or at least the illusion that I could make some of my own treatment decisions), and the hours were quite nice. I'd gladly do my sub-internship there next year (hopefully this calendar year) since I know how to work the system now. But so many patients just waiting for placement in nursing homes? So many patients coming in for altered mental status due to alcohol or drugs? So many patients in for COPD exacerbations with 150 pack year histories of smoking? Give me peds any day. Though I have to say I'm now a little torn on whether I'd want to do a Med-Peds residency instead of just a straight up peds residency. When I think of the quintessential doctor, it really is an internist. There is a huge array of medical problems you'd just never see in a peds setting (though apparently diabetes, obesity etc. are becoming bigger peds issues...yay), and I feel like for my own knowledge I want to know how to properly manage those diseases. Especially if I end up doing anything global health related...I've got to be ready for anything.
Today was my first day on the Hematology service at University...back into the world of chemotherapy, ANCs, and lots of things that are totally over my head. So much to do this month...hopefully I'll keep it all together.
Don't get me wrong, I actually really enjoyed the month...I liked talking to the veterans, I liked having a little more autonomy (or at least the illusion that I could make some of my own treatment decisions), and the hours were quite nice. I'd gladly do my sub-internship there next year (hopefully this calendar year) since I know how to work the system now. But so many patients just waiting for placement in nursing homes? So many patients coming in for altered mental status due to alcohol or drugs? So many patients in for COPD exacerbations with 150 pack year histories of smoking? Give me peds any day. Though I have to say I'm now a little torn on whether I'd want to do a Med-Peds residency instead of just a straight up peds residency. When I think of the quintessential doctor, it really is an internist. There is a huge array of medical problems you'd just never see in a peds setting (though apparently diabetes, obesity etc. are becoming bigger peds issues...yay), and I feel like for my own knowledge I want to know how to properly manage those diseases. Especially if I end up doing anything global health related...I've got to be ready for anything.
Today was my first day on the Hematology service at University...back into the world of chemotherapy, ANCs, and lots of things that are totally over my head. So much to do this month...hopefully I'll keep it all together.
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