Medical Types

I've become, in my old age, a consumer of watching people. I really listen now, really absorb who is right in front of me, and try to seek understanding of who they are. And in a teaching hospital, it is quite the array of personality types.

But I think I've distilled it down to it's basics at this point. It seems there are three "types" of people involved in the practice of medicine.

Dr. User
They seem to always want something from you to assist what they are doing, but rarely (if ever) offer something to you. They reach out when they identify your strong points, to augment their weaknesses. But they are the first to run for the hills if you need them or you demonstrate weaknesses yourself. If you are in trouble, these folks can't be relied upon or even trusted with your issues. They certainly aren't bad people or clinicians. But they are fearful, insecure, self-centered and driven to achieve little beyond what serves them best and first.

Dr. Standby
I'd say most of the people I encounter in medicine are "standby" folks. They wait in the wings. They don't come forward in hard or easy times. If you get into a jam, they wait silently close by and watch to learn from your mishaps, but are willing (although not excitedly) to assist if you ask. They aren't easily made friends of, but once they do accept you, they are all in. They are good people to know and have access to, but they aren't very committed to you or anyone else.

Dr. All-In
These folks are totally committed to everyone and everything around them. They don't hide in self serving practices and aren't shy about committing to you if you are open to it. They are accepting of everyone, every patient, every situation without a whimper. They are there for you when you need in hard and good times. They seem to approach more readily when they sense distress. They never appear burned out or disturbed by the people we live with or serve. They stand by you in good and bad times. They are likely the best friends to have in the long run and have the potential to be totally honest with you when you need it most.

I'm a Standby right now, a bit cautious. I strive to be an All-In. I think it's all about moment by moment focus, stress management, being there and approachable in good and bad times for colleagues and patients. It's about daily renewal and openness to the possibilities. Paging Dr. All-In, Paging Dr. All-In.

Cocaine

"Cocaine can constrict blood vessels in the brain, causing strokes. This can happen even in young people without other risk factors for strokes."

I've read that statement in countless books in school and journals studying the use of cocaine. I've always had a interest in the effect of drugs on the body growing up in South Florida where it's always been available. I've been interested in the effects since my days working in trauma and seeing the aftermath of use and abuse. I've seen people try to fly off balconies on LSD. drive into walls on alcohol and drive too fast for the curve on coke.

But nothing is more devastating than a deep brain bleed in a young person from a snort. It leaves the person alive but with greatly reduced function, with bills they can't pay, rehab that will never get them close to the way they were, and loved ones taking care of the rest. So sad.

Heros All Around

My new hero, Kayla Harrison ,78 kg of "kick ass". Great lesson; Don't get mad at the past, just GET GOLD! Awesome, amazing performance after years of total bullshit in her life. Way to go Kayla!! Absolutely inspirational.

First Month Done

Oh thank God it's August! I can finally sleep in my OWN bed... the simple pleasures of life.  The first month of residency is officially over and I've broken the ice on the "rest of my life". Beyond the cognitive decline of an aging clinician, I think I held up pretty well for an old guy.

Still the yungins are really, really sharp and I can tell already it's going to be a challenge to make the grade and keep up in some respects. We shall see. It's one day, one patient at a time. But for now, it's (I hope) a realy good nights' sleep in my own bed.

Ready for the End

This is the last weekend of my first block. It was challenging. 319 hours in 4 weeks, just one short of a violation. Over 400 pages for services to the floor. Untold number of scut monkey activities and moments of potential humiliation by upper class folk and attendings sprinkled with a solid 1/2 dozen moments of amazing connections with family and/or patients.

And it's those few moments that fuel my love for what I'm doing and yearning for more. I think I can put up with almost anything as long as those moment continue. And I know that that part of the equation is up to me. Because I know I have little control over any of the rest of this madness and mayhem they call residency, filled with strange rules, hours, notions, myths and activities.

Yet at the end of any brutality is the notion that one can survive almost anything. And then onward to the next block of work, education and hopefully more time for me. Remarkably, I am about to survive and this is my last weekend. And, I think I'm ready!

Let the games begin

I think medical education is constant search for diversion and distraction punctuated by the complete lack of sleep. Let the games begin!!

Love the Ralph Lauren USA garb, made in China :)

Dragon Speaking

"ice on a dill" = lisinopril

Voice recognition dictation can be so so entertaining

Loving what you don't like

It's inevitable. Experiences in medical education, or in life for that matter, that you file away in "I'm sure I don't like that". And then you set about a way to avoid it, to the best extent possible. But still staying politically correct, snuggling to the correct person, and stating the most obvious sarcasm you can muster... "I love this [thing you really hate]!" Although hate is a strong word, certainly something you will try to avoid. It just feels wrong.

But somewhere in the political correctness, the lies about what you say you like but don't, is a spiritual nirvana and real message in the "hate". We learn what we don't like but still take away a greater knowledge, experience and appreciation for that thing or experience.

And so is the life of an intern. Moving through the motions of learning so you can be a working physician, figuring out what you like and what you don't like, but still learning...always. Every skill, every nuance, every opinion, every fact; Adding to the knowledge base that is your toolbox for the future practice of medicine and patient care. Always with the knowledge that there isn't anything that they can do to me in one rotation that I can't get over. But a positive lesson on something, even if it's negative, every single day.

------------------------------------

There is no way possible to fix the current medical system quickly and easily as long as it's core is made up of professionals that believe that the old way is the only way. Sadly it's those old ways that have brought us to this broken, unenviable place in U.S. medicine.

Cost of doing bad business

She said "I ran out of my medications" and couldn't afford to get them.

Cost of medications for the month not covered by insurance, $85

Cost of the Emergency room visit for the hypertensive crisis plus the ambulance ride in, $2800

Does this make any sense to anyone?

It's not mine

There are few things that are more disturbing than to hear those words from physicians who are in the business of attending to and working with patients..."It's (referring to a live, breathing patient) not mine"

Let me get this straight. The patient needs your services, but "it's not yours?" And the it, ...that's Mrs. Bernstein. I know you are tired, so am I. I know your reimbursement won't be maximal, but who's is. But she is yours. You are a neurologist with expertise in meningitis, you are on call, and she does have meningitis.

So it, her brain and it's surrounding meningeal structures, are yours.

Healing in the modern era

This has gotten so complicated. Financial issues prevent or alter access. Why not use the ER for your primary care. They can't turn you away, even if you don't have the co-pay. So, so broken...

Luxury

Nothing too good for our residents. I have the luxury top floor penthouse suite

Letting Go

Medicine is a strange training ground. So much pressure to compete. So many lost opportunities for real collaboration and real team work. Mix that with sleeplessness & stress and you have a potential challenge.

Letting go of the tendency to hold ourselves up to other people’s standards, and letting go of the belief that we need to compete and win, doesn’t mean we don’t believe in doing the best job we can.

I love baby Pandas.
But I digress.

Reality

The hospital ED has a way of dealing reality to both patients and providers.

Reality: that which you were formerly clueless on, becomes clear as a bell.

Value

Without good teaching and teachers the process of learning in residency can become disheartening and destructive. But with good mentors and teachers, it holds promise and value to be both gratifying and productive. We shall see.

First Days of Residency

The first days of work were a little challenging with the hours, demands and (most of all) the reactions of the patients. Do you think it had anything to do with my shirt?

Survived

First of anything are usually a challenge. It certainly was my first night on call as an intern. They said it wasn't too busy, but it felt like an avalanche to me. Fortunately all the patients did well and the only faux pas on my part...walking into a "isolation" room without a yellow gown. I learned to read door signs more carefully.

Of course the patient load/calls were compounded by not knowing how to get places, how to use the electronic medical record, or the "norms" of the hospital and staff. It was challenging to integrate medical school and my experience into the work of getting through the night. But I survived. Barely. I fell asleep after my 14 hour shift during morning report before going home.

And so it begins. The residency learning process in the face of overwhelming responsibility, not enough time, not enough staff and a learning curve as steep as Mt. Everest. But I'm determined to make the climb, one step, one day, one patient, one decision, one new EHR skill, one nap, one admission, one order at a time.

July Effect

July 1 each year is the start of residency for several thousand medical school graduates. That is the where the term "July Effect" arises. I am, starting July 1, part of that effect.

My colleagues in law, and business get so excited when they speak of internships. Companies with big names and even bigger reputations are discussed freely. Visions of suits, handshakes, networking breakfasts, long hours and potential job offers to follow usually accompany those discussions.

But for those of us in medicine, internship is more akin to a form of indentured (or edentulous) servitude. It is that first year when you have no sleep, no very little, have high amounts of activity, and no opinion (at least none that matters to anyone). On the food chain, even medical students are treated better (they go home early usually). It is a very different look and feel.

So now it's my turn to become part of the productive, or dangerous, time called internship. For the next year, beginning on July 1, I will become part of the 1000's of first year, PGY (Post Graduate Year)-1, residents... aka Interns. I'm scared, excited, worried, elated and I'm hopeful to be at least able to find my way around this massive medical center.

I am also going to become part of the "July Phenomenon", that time when experts have said to stay healthy and avoid the hospital due to up to a 10% rise in medical error. That is the first month that "we" are there, doing our doctor thing, in the very first month of our training practice. There have been arguments over the years if the effect actually exists, but from the looks of the PGY-1 class around me, I think the world is safe... as long as they are continually hovered over and supervised.

And so it begins. The years of medical school have led to this point in time. You really can't do much with a medical school diploma so this is where the rubber meets the road so to speak and we translate our knowledge into real, tangible patient care.

I'm scheduled for a opening schedule of 160 hours over the next two weeks with only one day off in the next 14 (not a violation of the new GME hours rules).

Ready or not hospital, patients and staff,

HERE WE COME!

Longevity: 4 Years and 1/2 way

It's really been a long gestation, but I birthed the credentials that I've been working toward for the past 4+ (depending on how you count the years) . In no particular order:

1. M.D. diploma
2. ECFMG certification of education
3. Residency match offer/acceptance
4. State M.D. resident license

It's a slow, slow delivery with much frenzy in the last year, but the "quads" have been birthed. And as I start my unpaid orientation for residency, I'm excited to be at the 1/2 way point "finish" of my education and training as a physician.

Throw on top of that a new hospital I.D. card, some new embroidered coats, and it becomes an "ahhhh" (like right after the baby delivers) moment

This point in time was a distant dream when I first got accepted to medical school and began this trek. And I say 1/2 way because given a 4 year (maybe 5) residency/fellowship course of study to follow, I've literally only completed 1/2 of the necessary hurdles to full medical practice licensure and board certification.

The process to get to this point is truly amazing, on so many levels.  It's been a cascade of emotions, effort, trials, schedules, deadlines and processes. It's hard to believe sometimes that anyone actually completes this process, but with one day at a time, enjoying every single moment, it is possible and feels great.

Literal Bible in Practice

I’ve read this several times in the past. It’s not new and it’s not mine, but it still tickles me. Sometimes we just have to step back and really assess what we believe, why we believe it, and the mass effect on the community and culture around us as we strive for cooperation, peace and a world we can proudly leave our kids.

Dear Dr. Laura;

Thank you for doing so much to educate people regarding God's Law. I
have learned a great deal from your show, and try to share that
knowledge with as many people as I can. When someone tries to defend the homosexual lifestyle, for example, I simply remind them that Leviticus 18:22 clearly states it to be an abomination. End of debate. I do need some advice from you, however, regarding some of the other specific laws and how to follow them.

1. When I burn a bull on the altar as a sacrifice, I know it creates a
pleasing odor for the Lord - Lev.1:9. The problem is my neighbors.
They claim the odor is not pleasing to them. Should I smite them?

2. I would like to sell my daughter into slavery, as sanctioned in
Exodus 21:7. In this day and age, what do you think would be a fair
price for her?

3. I know that I am allowed no contact with a woman while she is in
her period of menstrual cleanliness - Lev.15:19-24. The problem is,
how do I tell? I have tried asking, but most women take offence.

4. Lev. 25:44 states that I may indeed possess slaves, both male and
female, provided they are purchased from neighboring nations. A friend of mine claims that this applies to Mexicans, but not Canadians. Can you clarify? Why can't I own Canadians?

5. I have a neighbor who insists on working on the Sabbath. Exodus
35:2 clearly states he should be put to death. Am I morally obligated
to kill him myself?

6. A friend of mine feels that even though eating shellfish is an
abomination - Lev. 11:10, it is a lesser abomination than
homosexuality. I don.t agree. Can you settle this?

7. Lev. 21:20 states that I may not approach the altar of God if I
have a defect in my sight. I have to admit that I wear reading
glasses. Does my vision have to be 20/20, or is there some wiggle room here?

8. Most of my male friends get their hair trimmed, including the hair
around their temples, even though this is expressly forbidden by Lev.
19:27. How should they die?

9. I know from Lev. 11:6-8 that touching the skin of a dead pig makes me unclean, but may I still play football if I wear gloves?

10. My uncle has a farm. He violates Lev. 19:19 by planting two
different crops in the same field, as does his wife by wearing
garments made of two different kinds of thread (cotton/polyester
blend). He also tends to curse and blaspheme a lot. Is it really
necessary that we go to all the trouble of getting the whole town
together to stone them? - Lev.24:10-16. Couldn't we just burn them to death at a private family affair like we do with people who sleep with their in-laws? (Lev.20:14)

I know you have studied these things extensively, so I am confident
you can help. Thank you again for reminding us that God's word is
eternal and unchanging. Your devoted disciple and adoring fan,

Jack