His story, Her story

Everyone has a story. Everyone has tales of woe and triumph about this abortive process called medical training. The stories are all about the trials and tribulations, the attendings, the rotations, the schools, the classmates, the exams, the sleep (or lack thereof), the process, the residencies, the hours, the longer hours, the memory (lapses). And we all seem to have the same response on any given day...one day at a time, moving closer to the goal, whatever that is for you. It's a daily slog.

And it's so great to find those of use who relish, thrive and look forward to the learning day. There are great mental triumphs and "oh wow" experiences of eureka, mind blowing understandings of new, or newly incorporated knowledge. And it's those that force people to answer the question, "how are you?" with "I'm EXCELLENT!" :) and really mean it.

The process can be a great challenge.

But, today, I'm EXCELLENT.

Thanks Ceriman, the waiter, for reminding me of that simple fact. It's not what happens to us, but how we respond to what happens.

Mortality

I've learned to equate "clinical trials" of medications on people with illness as a terminal event, one step closer to death. It's just the places I've hung around, people I've worked with and things I've seen, but the the two -- Clinical trials & terminal -- just seem to go hand in hand.

One of my friends from way back when I was too smart for my own good, just told me she's in a "clinical trial". I felt sick...for her, and her family. She's so upbeat, so positive, so able to move through the day with a huge smile on her face. That same smile way back when, won her awards. Now they hide the sad fact that disease is ravaging her body.

I'll pray, I'll hope, I'll stay positive for her when we speak. But I've become acquainted again with mortality.

One, more, STEP

Seems like I've been studying medicine my whole life. Oh wait, I have! And it seems that it really all comes down to this set of two exams...Step2 "clinical knowledge" CK, and Step2 "clinical skills" CS. The entire reason for being comes down to two day of exams, one live with patient actors (and I use that term very loosely), and one "dead" day with a computer for 9 hours. Then sometime this fall, two email messages, and attached PDF's announcing the fate...Yay, or nay, to have the opportunity to graduate, get the MD in hand and move forward into the next part of training, the residency.

Rotations have been great. I'm in my element. I love the patient, the clinic, the learning, the relationships with staff, the smells, sounds and activity around healthcare. Lots of people are disgruntled in the field of healthcare, but I largely ignore them. Rotations are signs of things to come, residency and practice beyond. This really is the essence of why I did this in the first place. I am encouraged.

I thought she said "your ass" when I first heard the description of "what next" from one of my classmates. Actually E-R-A-S (residency) application. It is truly time consuming, but a necessary evil and it too continues getting ready for the 2012 match with 35,000 close medical friends who will also apply. Letters, documentation, work history, blah, blah, blah. Seems like I've been filing paperwork my whole life too. Oh wait; I HAVE!

So I study, and study, and study some more. It's a race against time, knowledge attrition, creeping dementia, boredom, mind numbing fear and a touch of ADHD. It's a balance between sitting for long hours, exercise, sleep, eating right and knowing just how much caffeine I can bear without overdosing.  It's keeping an eye on the prize and doing what it takes, even if I should have found "another career" (- career counselor, 1977). This 2nd step isn't the last step, but it's the one that really counts and "bookends" the process of the past 4 years. It's exhilarating, and frightening in one well wrapped package. My date with destiny coming very soon. Emails forthcoming.

The Cycle Begins

It's that time of the year that those shooting for Match 2012 in March begin the cycle of paperwork, processes, letters of recommendation, applications and interviews begins. The cycle starts now, in July, and ends the day the "matches" are announced in March.

It's worth reflecting how the process ended in 2011. Match Day 2011 there were 30,589 "active" applicants, and 23,421 PGY-1 slots available. Over 7,000 walked away with nothing after many years of hard work and the effort. Many will apply again this cycle, but likely many will walk away into other fields of work and study.

It is the bottleneck. It is the part of the system that is the real problem with the system. Medical schools are expanding their class sizes even as new programs are created for new students, both D.O. and M.D. But the sad fact is that the number of positions in residency are not increasing as fast. Thus, more and more physician graduates will not have post graduate residency positions to enter. And the problem is only exacerbated by the number of physicians immigrating into the U.S. each year, also in the hunt for those positions.

And so the environment I enter now. I'm so impressed how little information is out there that is consistent to help make the many decisions that have to be made in the next months. I'm on a haywire way up high without a net. This "fly by wire" is a rush, but it be the first step back to waiting tables too!

Education of the Un-schooled Kind

I was really frightened many years ago, helping take care of my first cerebral palsy (CP) patient. There was this really grotesque looking and acting child with muscle spasms, head shakes, twitches and writing sitting in a wheel chair. I thought he would break. I thought I might break. But that was many 10's of 100's of patients ago and I've heard and taken care of CP, cerebral palsy, patients forever. It's not a new name or category of care for me. But I've been schooled this past month. I really didn't know CP at all.  

Then I met and really hung out with a bunch of CP affected folks and their families. I really appreciate the experience and am so grateful for being able to hang with some of the most phenomenal but individually different CP folks ever. Everyone different from the next. Somewhere during the last few weeks in that experience there was a "click" of information (my anatomy, physiology and neurology) with reality. And after this intense month of talking with and experiencing these amazing young people, I now realize how diverse this group of patients is.

Cerebral palsy is considered a condition but it's really a waste basket term for everyone suffering from injury (usually some form of anoxia, low oxygen, at birth). It's more often thought of as a group of disorders that involves injury to the brain. But the problem is that the physical manifestation of the damage depends on which part of the brain and it's pathways are damaged. As a result, no two patients present the same and have differing combinations of functional deficits in movement, learning, hearing, seeing, and thinking. Each one is different.

The brain is huge and has between 10 billion to 100 billion neurons organized into cortices, pathways, areas and regions. Imagine all the different combinations of connections between those neurons and you have a number that is representative of the true nature of CP and the number of possible presentations.

So the first patient may have sight problems and motor control on the left side of his/her body. The next patient may have lower extremity problems and normal above the waist up. The next may have speech creating deficits and be unable to walk or hold a fork in the right hand but can with the left...and on, and on, and on go the variations.

But what I really learned I learned by hanging out with them and hearing their stories, successes, triumphs and fears. They are creative, fast thinking, smart for the most part with incredible senses of humor about themselves and others. They are dedicated, and grateful since they don't know what they don't have...they never had it. They are sincere, loving, hard working and diligent to find their niche in life while serving others. They really are, as one mother put it, incredible kids often trapped in bodies that just don't work. I really have been schooled...and I really am a better student, provider and person for having done so.

Tis the Season

Tis the season, not to be jolly, but to apply. And so it begins...the 2012 Match ERAS season. This is the start of what will be the long months leading to the that fateful March date when everyone I know will be fighting for residency positions and hoping someone says to them..."we want you". I don't know if I'll make the 2012 match, but I'm going to give it my best shot.

It's a frightening process filled with more sources of information, speculation, advice, land mines and unknowns than I care to envision. All the elements must fall together in a pattern of "presentation" so the director of said residency programs feels you are a "match" with his/her vision of his/her specialty in his/her community. Dean's letters, letters of recommendations, tokens, Step 1 scores, supplemental  applications, Step 2 CK and CS scores, grades and evaluations from rotations, etc etc. And then how to decide which specialty, at what program, where in the world?

Having watched good friends go through this process, it's really awful. It's not a system that really matches proportionally to the many factors that a person has. In many cases, your personality and bedside manner never see the light of day if you are a struggling test taker. Getting the interview..that's really the goal. And hopefully figuring out where your best chances of "match" are before you click "send" the applications out to the many programs.

And so it begins. I'll try to figure out this process and hope that each day I'll inch toward that letter of "we want you" and it'll be a place I really want to be. Marriage was easier. Actually, pulling that ice pick out of my leg was easier.

Humanism

Sometimes within the madness, mayhem, schedules, rushes, indignities, cost over-rides, dissatisfaction, liability, pain, suffering, aggravation, selfishness, greed, industrialization, government oversight and processes of medicine...there are moments of pure giving, love, joy, healing, service and art.

I don't want to miss any more of those moments. Glad I didn't miss this one. It is the fuel for moving onward, even if I have to battle the testing beast soon. It a real honor to be involved in the relationships that have become my profession.

Transparency in Medicine

Transparency

1. free from pretense or deceit
2. easily detected or seen through
3. readily understood
4. characterized by visibility or accessibility of information especially concerning business practices

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I am regularly struck by how much research patients often do before coming to the doctor. The Internet provides a full gateway of information and, unfortunately, misinformation about diseases, treatments and the system of medical practice. The Internet has been an effort to provide greater transparency in how we practice medicine and deliver healthcare. The written word seems to hold great validity to patients.

Transparency is fundamental to the creating of trusting, nurturing relationships with each other, particularly between clinician and patient. If for a moment the patient believes that communication and information provided is full of pretense, lies, or is not understood, there is immediate breakdown of the relationship and (if medical social scientists are correct) the cooperation of the patient in his/her care or "compliance". So the real question, is there transparency in medicine?

The reality is that transparency is scary to clinicians and the system as a whole. There are elaborate efforts to fully but not completely, reveal the secrets of medicine and medical practice. The Internet has done major things to this "gap" but rely on patient understanding, so would seem to violate "readily understood" transparency. Has the Internet then helped or hurt?

Transparency in the system is really up to the clinician. It's not the patient role or within his/her ability to force transparency through the Internet or available information sources. While it's all "out there", it may not be all understood and may actually contribute to damaging the relationship between physician and patient as they often believe what they read over what is being said.

So in that lies the greatest opportunities for improving patient care, trust and compliance...creating transparency with each patient we encounter. Yet there are risks in doing so as magnified by the legal system. However, taking risk offers great rewards. We should embrace our fear with honesty and transparency.  But that would be in the perfect world with tort reform, liability caps and a system that supports that perspective. I'm not optimistic.

Another surgeon quit working this week. Tired of dealing with being questioned by everyone about how he practices. Another good surgeon, out to pasture.

Service

One of the unsung, unmentioned perks of medical education is the access to quality experiences of service. These opportunities come in small packages, like tiny and discreet words with patients or families. And they come in larger packages related to hearing about real community needs. I had the chance for a sort of large one, more medium in scope, but VERY LARGE in effect. I helped a family clean out an apartment of a family member who died from suicide after a long, long battle with cancer, drug abuse, alcoholism, cirrhosis, pancreatitis, heart failure, kidney failure and emphysema. The physical, emotional, intellectual, and spiritual benefit of this day long effort was tremendous.

But one of the most striking elements of this event was the short list for "shopping" the deceased had created before his death. He simply wrote on a small, pink Post-it note: "comet cleaner, scrips, beef w/barley."

I've been trying to wrap my head about around the whole experience and the grateful family for stepping up when few others did except to come salvage personal belongings of the deceased.

Cleaner, drugs and soup seems to punctuate the simplicity, commonality and routine of a life in great pain, alone, struggling in the end to find a reason to live, clean the apartment and eat, until it became why bother.

Surgerizing

I am REALLY in my element.

A chance to cut is a chance to cure.

But the pathology is so, so devastating.

I am so blessed to be whole, and not have someone leaning over me wielding a scalpel.

Really looking forward to Easter weekend and the last days of Passover week. A great time to pause and give thanks.

How to Value Medical Students

Teaching is more than a business in medicine. Medical students, interns, residents and fellows have real needs. We all do. Address the needs and you make a friend for life and influence the future of medicine in a meaningful way. Such are the qualities of good clinical preceptors, teachers of medicine and surgery. I've had some good ones.

So what needs did he or she address? Certainty, variety, significance, connection, growth and contribution.

Learners want to know what's expected of them (certainty), experience a cross section of pathology (variety), feel they are important (significance), be a part of the team and treated as such (connection), learning (growing) and feel as if they have helped in a meaningful way (contribution).

It's hard to teach the importance of basic human needs to teachers,... individuals who are often struggling to have their own needs met.

Patient - Clinician Relationship

I have met some really good clinicians lately; Individual who create great environments of trust, communication and cooperative healing with patients.

It's really pretty simple. There is ALWAYS a gap between what we expect of our patients, and how they act. I've noticed that the most disturbed clinicians assume the worst about that gap. Positive, happy clinicians seem to believe the best, come to the defense of their patients, speak directly to the patient (and not in the hallway to others) about those gaps, and create REAL trust with the patient so he doesn't feel judged or persecuted when they come to visit.

"Do unto others (patients) as you would have them do unto you (if they were the doc)"...We should protect, trust, hope and persevere more.

It really is pretty simple and probably applicable to the rest of our relationships, even outside of work.

Still Engaged

Whenever I engage solo or groups of physicians I really listen carefully to what they say about this profession. I try to discern what it is they do, how they feel about it and what they believe the future to be. I'm constantly reminded of how many physicians are unhappy with what they do and why. I hear complaints about patients, insurance companies, the government, systems, and on and on. I'm convinced that there are more unhappy people in medicine than any other profession, but I don't interact with any other profession (sampling bias).

So the other day I met a very interesting surgeon, visiting the area. He practices in a small country in Africa and is the chief of surgery in a large (by African standards) teaching hospital. Listening to him speak you would have thought he had been given the gift of levitation. The pride and happiness almost oozed from his pores. It was a refreshing view into the life of a physician who really was happy with life and wholly feeling the "honor" of being a healer in a country desperately in need of healing on many levels.

One thing I'm certain of. I'm happy as a little clam. I love the content, the work, the patients, the material, the environment and the comrades. I'm learning to ignore the bitching and see past the complaining to the value in what we do and how we effect others. It's refreshing. Just hope I can maintain it thru this amazingly retarded system they call medical education.

And the surgeon, he invited me to do a "rotation" in Africa. Why not? I don't think Medicare is a discussion point there.

And exactly how do we know little clams are happy?

Don't Eat the Eggs

Two days of lecture have me whipped. Sitting is becoming my least favorite activity in the mode of learning. Learning by doing (preferably walking, running or actively moving in some anatomical way) is my preferred. But the content was good and a reminder of how much I have to study before my next big exams. I need those subtle raps in the head occasionally. But what I didn't need was the rap to the GI tract. Note to self: Don't eat the eggs at a medical conference.

Inconvenient Truth

The truth is surgery has a terrible time clock, and doesn't respect time in any way. Things happen good and bad that alter the "clock" and have things start and end when they weren't supposed to, or expected. It's just the way it is, and everyone around us is supposed to know that, honor that and just bear with it. But still, it never feels quite right.

And so it begins again.  My absolute and complete love-hate relationship with the discipline, or lack thereof, of surgery. We cannot escape the barber-istic past. So let the anesthesia begin.

Sanity Defined

Sanity is being judged "of health & sound mind" and being to make well judged choices. The appearance of sanity seems to be the one thing everyone wants but really can never get when we finally understand the real truth, the whole truth and nothing but the truth...We are all a bit crazy. To the extent that that crazy affects your home, work, professional or other (activities of daily living) life is the extent that you are judged insane by professionals as guided by criteria set up in the Diagnostic and Statistical Manual of Mental Disorders (DSM).

And now changes are coming to the DSM and the 5th edition is to be published for use in 2013.  Seems that the science (practiced now mostly as a subjective art in community practice) has been propagated by researchers who have generated a wealth of knowledge about mental disorders, biochemistry of behavior, the influence of genes and heredity on mental health, and other factors begging to be described and included in the new book.

It's been 18 years since the last revision (the one currently in place) and begs the question. Will what is now sane become insanity or will what is now insane become sanity with this revision? It is theoretically possible that patients deemed "normal" now will suddenly find themselves not so normal after the publication of a book. Fascinating!

And then, the psychiatry rotation was over. And God said it was good. And before he created the next rotation, he contemplated the sanity of man and deemed woman a pre-existing condition. Man seeking his sanity discovered electricity and ECT was born. Man chose electric shocks over woman. And all was good again.

Joan, Jane, John etc...Meet Dr., Dr. Dr.

My "Tara" experience came early in my psych experience.  "Tara" is the character played by Toni Collette on "The United States of Tara", the Showtime TV show about a middle-aged, married, mother of 2 kids who has dissociative identity disorder. For the older folks this disease is aka multiple-personality disorder (MPD) and was associated with "Eve" and "Sybil", who are unknown by my 20 something colleagues.

It became apparent very quickly that I was totally ill prepared for the Tara experience with my Barbara Bates (Hx and PE textbook author), linear, history and physical examination style. There is nothing linear about the "new patient" work-up of a multiple, particularly as the personalities come out and interject, or worse, correct each other. Such was my experience.

I sat with Joan, Jane, John and some other un-named personalities for a long time hearing the history, fact, details, summaries, ranting, ravings, lies, delusions and such. It was the most entertaining hour I've ever spent in medicine and I'm a better provider for it. But my real conundrum as a provider came the moment I sat, pen hovering over the progress note page, and tried to write this encounter up in some manner that was intelligible and demonstrated my expertise as a medical professional:

"Personality #1 (called herself Jane) related a history of sexual abuse at the hand of her father and noted no other physical, verbal, emotional, financial or sexual abuse history. Personality #2 (Joan, deeper voice with faster cadence and visible tremor left hand) immediately corrected "Jane" and noted that she had been financially abused by a Texan with a big car just a few day before this visit. Personality #3 (John) then noted that Jane was Jealous, and that Jane and John were really wanting the Texan's money..."

And so it went. And who was Jealous? John was actually talking about another personality, within a personality. Apparently personalities can have names of emotions  too...a variant presentation.

I have to admit, I felt a bit hoodwinked but still entertained. That's the thing about Psychiatry in general. There are no blood tests or real objective testing for many of the diseases we encounter. Such is the case with MPD, now DID. The interview is all we have. And if it is, we are totally unprepared. At least I am. But then, that was the best afternoons so far. No wonder Tara is a hit show on Showtime.

Mental Health

Who we are, and how we respond to our environment as a living, breathing, interacting organism is a function of our nervous system. And that nervous system made of nerves, our spine and our brain is largely a function of chemicals...norepinephrine, epinephrine, serotonin and dopamine. So beyond limited therapies of counseling (a mainstay of psychiatric care), restraint (physical and chemical), and controversial surgical and electrical brain intervention; Psychiatry is largely an attempt to modify those chemicals.  Today, 4 % of men and 10 % of women in this country are taking antidepressants at any given time according to Dr. Julian Whitaker.

So the day to day operations of a psychiatry office, and the function of a student in that environment, is the management of those drugs that attempt to modify those chemicals. The drug names of many, varied, and often entertaining....and  there are MANY, with new ones coming out almost hourly. You can barely get through a TV show without seeing a commercial for one.  We sell psychiatric illness and the "cure". It has become the mainstream of what we do in psychiatry and sales have skyrocketed from about $500 million to the current almost $60 BILLLION in only about 20 years. It is BIG business and the number of drug company sponsored lunches I have eaten while doing my psych rotation is testament to the amount of expendable dollars available due to these sales figures.

"The way to sell drugs is to sell psychiatric illness."----Dr. Carl Elliot, University of Minnesota Bioethicist (The Washington Post, 2001).

And while I feel well fed, and likely that some people actually need this care to survive life, much of what we do in psych is suspect at best and in some cases dangerous. Dr. Peter Breggin, M.D. says, "Going to a psychiatrist has become one of the most dangerous things a person can do", referring to the chemical approach to care.

And we continue to sell both disease and illness to a large percentage of "patients" walking thru the door, but the stories are largely of "life" and the stressors we encounter along the way. Has our ability to handle life and the massive stressors been exceeded or do we just look differently at that ability (and possible treatment)? It appears that current psychiatric practice is largely the latter.

"[W]e do not know the causes [of any mental disorder]. We don’t have the methods of ‘curing’ these illnesses yet.”----Dr. Rex Cowdry, director of the National Institute for Mental Health (NIMH), testimony before a House of Representatives Appropriations Committee Hearing

But there are some severely wounded people out there with real, significant and life strangling psychiatric issues. And it's those people that we daily struggle to help live a life with some quality and as few bumps, injuries and maladies as possible. And it's largely that hope that keeps the doors open, and the drug company lunches coming. We really want to help those in need, but we continue to invent, modify, and alter need. It is a grand experiment for sure.

"Anyone who goes to a psychiatrist ought to have his head examined."-- Samuel Goldwyn

"Biological psychology/psychiatry is a total perversion of medicine and science, and a fraud."— Neurologist Fred Baughman

"Psychiatry is probably the single most destructive force that has affected American Society within the last fifty years." – Dr. Thomas Szasz, Lifetime Fellow, American Psychiatric Association

One Down, Some To Go

The first rotation is about over and time to reflect and transition to the next. I've really enjoyed the site, preceptor and the plethora of pathology. GREAT learning for sure. I also know that a constant diet of diseased vaginas, cervices, uteri and ovaries won't be my full time gig anytime in the future. Great to know that I understand the nuances of the specialty though. I'm sure I'll see much of this again.

It's been quite the tour of the female system in health and wellness from the technically specific presentation on pipette removal of egg parts and sperm chromosome modification of grand rounds, to the more mundane emergent patient presentations of membrane rupture, premature labor and peri-natal bleeding. It's also been quite the education in the finances and politics of healthcare. A sad, sad commentary on how the U.S. treats it's citizens and the right to healthcare.

I find it fascinating that while we pay taxes to keep public school running in almost every state and jurisdiction in the country, we have the most split, fractioned mechanisms for providing basic health care to the populations most at need. I find it unconscionable that we spend billions on destruction and rebuilding other countries and find it hard to find moneys' to address the core nutrition, peri-natal, and women's health care services. To be more specific would violate HIPAA and many other federal laws, but to not feel the issue at the jugular level is inhumane.

So we move through the day, one patient at a time, doing what we can do. I appreciate that there are some seasoned clinicians who have the time, resources, morals and ethics to do what is necessary, when it's necessary for who needs it most. I've been lucky to meet and work with some of them this past month. Hope the next one is more of the same.

No Wonder

A recent patient, all of 16, told her story in what we call the "history". It was clear that her problem was a gynecological infection and it was just a matter of getting to the final diagnosis and treatment through some easy, in office testing.

But I found myself hung up on the social history and explored that deeper than usual. How'd it come to this, I probed. What resulted was a scenario that left me with the feeling of "no wonder."

No competent family, parents or friends available or present. No one being attentive to education and social issues. No kindness, fun or light-hearted playing. No one to be playful when possible or serious when needed. No real love, forgiveness, honesty or truth around her. No appropriate feedback, critique, direction or guidance. Mostly hurtful words, being ignored, emails and texts not returned. No real genuine interest from others for her well being or needs. Nobody to share concerns with or speak the truth with. No respect, and no hellos, "how was your day." No open hearted love or trust, but plenty of vulnerability, people walking out or away, grudges, pride and ego. Most of all, nobody walking in, when everyone else was walking out and no unconditional acceptance, love or support.

 

This bout of a STD may not be the worst of her problems in life. The foundation has been cast, mostly on shifting sand dunes, empty promises, unkept responsibility and unattainable dreams. Pretty sure she'll be back, maybe pregnant next time.