Terms Everywhere

It's all about vocabulary.

Anything protected from outsiders must have a code that only the insiders know. That vocabulary of terms is the "fair maiden", protected in the towers by the knights in white smocks with black rubber tubes of grail around their necks and in their ears. To know "the words" is to be a member of the secret society of potions and spells that few are permitted to use or allowed entry.

 

And when the attacks at the gates by nurse practitioners, physician assistants, chiropractors, pharmacists and the many "non-knights" becomes too brutal, the knights convene and invent new words, new exams, new "steps", new rules, new regs, newances...and they smile broadly.

Pneumonoultramicroscopicsilicovolcanoconiosis

Mu ha ha!!

That'll keep them to the other side of the mote.

The fair maiden is protected again.

Cluster Headache

Pretty darn bad, apparently.

A cluster headache is one-sided head pain that may involve tearing of the eyes and a stuffy nose. Attacks occur regularly for 1 week to 1 year, separated by long pain-free periods that last at least 1 month.

They are "episodic" (most common) with 2 or 3 headaches a day for 1-2 months, brief HA free period and repeating pattern after that. The other type is "chronic" is about the same but without a period of sustained relief. Both are more common in men, and often feel like " an ice pick in the eye."

Of course it's always a good idea to see if the patient actually does have a pick in the eye before treating.

Sorta Just Snuck Up On Me

The patient struggled to the table. "This has been progressing for a few months and is getting worse. It just sort of snuck up on me, a little more each day, week.

I've had tingling over my body in different place. I'm numb here, here, here and here (pointing). I can't seem to keep my balance on uneven surfaces and have been falling a bunch. My legs and arms feel so weak and my vision is getting worse, almost daily. I've been seeing double and it's very blurry."

"How old? I'm 48 doc. I'm very active; at least I was. I drive a tuck for work and love to hike and bike with my wife and kids."

[pause]

"Lets get a MRI and see you back. I have an idea what this is all about, but I want to be sure."

"I'll want to run a few more tests but I'm sorry, it is what I thought. You have M.S., Multiple Sclerosis. I'm afraid you may not be driving anymore and while we have some treatments that will help control the episodes you have been having, this may get worse over time."

And that's how it is. One day young, active, hiking and biking...the next, struggling to get up from a chair or climb stairs.  And the presentation, signs and symptoms are as varied as the stories with many different nerve maladies affects:

Multiple sclerosis is an autoimmune disease that affects the brain and spinal cord (central nervous system). Symptoms vary, because the location and severity of each attack can be different. It usually happens in "episodes", period of time with symptoms and many patients can be kept in remission with various therapies, medications etc. Episodes can last for days, weeks, months....or forever.

For me, after my neurology rotation, it will always be the "just sorta snuck on me" disease.

Get rid of my headache doc, and I'll give you my daughter!

Migraine headaches suck! That would be an understatement to those really having them. Migraines create great dysfunction in life, work, relationships, mood, self esteem, eating habits, traveling habits and almost every other area of life.

So when a patient finds a cure, usually through a provider that's willing to walk the combinations of medications (both rescue and suppression), other therapies and time... patients are ecstatic. Now they don't normally give away daughters and other parts of their family, but they do make grand gestures.

"How are you headaches going Mr. Jones? We've had quite the challenge with these, haven't we?"

"Doc, they are GONE!! I love you!! That combination of [select from the buffet - Amerge, Axert, Frova, Imitrex, Maxalt, Sumavel, Treximet, Zomig, Botox, Migranal, Ergomar, Caffergot, Amitriptyline, Atenolol, Diltiazem, Doxepin, Verapamil...just to name a few] did the trick!"

"That's great Mr. Jones.I'm thrilled for you and that we could finally get you some relief. By the way, I love you watch. It's very nice. Ok, so I'll see you back in about 3 months to see how your doing."

"Sounds good doc. Here take the watch. It's just an old thing anyway. Enjoy it!" And with that, he handed the doc the watch, and walked out.

Thankful just doesn't cover the gesture.

Furiously Filling Fat Full Fast

I am so full of knowledge at this point, I'm afraid to learn anything new for fear that it will force something out that I might need later for exams, practice or human conversation. I don't think there is any room possible for any more. I'm almost completely full.

And just in time too. Nearly done with this phase of study and the next exam coming soon. It's anticipation and future relieve rolled into a tight package of anxiety. The ultimate performance anxiety.

I've met some interesting folks these past weeks of intensive study; all on the same mission. We all have our strategies for success and they couldn't be more different from each other. But the ultimate goal is the same. Fill up just enough to not push anything out the other side of our brains and promptly regurgitate what we know or think we know at the appropriate time, in the appropriate exam moment so we can onward to the next "Step".

I pray for no leakage of any vital information, including my name.

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.