Psychiatry – Day 5

This post includes discussion about suicide. If you or anyone you know is struggling with thoughts of suicide the National Suicide Prevention Hotline is 1-800-273-TALK (8255).

New week and with it an attending change. Of course the day I run out of scrubs and come in business casual is the day with the one psych attending that wears scrubs. If the attire and long flowing hairs wasn’t enough of a tip-off, his practice style was very chill. The way he talks with patient’s is very familiar (in the sense that the way he present himself is very down to Earth and comforting).

At this point I’ve gotten a couple opportunities to talk to patient’s struggling with suicidal thoughts. Today was my first time talking to a patient who was feelings actively suicidal. From my perspective, what was difficult about the conversation was it felt like talking to a wall. This person had been struggling with depression and suicidal thoughts for several years. They had tried various treatment options without any respite and they just want it all to end and they resent the world/ society for not allowing them to follow through with. As heartbreaking as it was to hear them speaking, I also thought what they were saying is reasonable. I can’t feel what they are feeling, but I can only imagine if I were going through years and year of torment and people saying they can help me or that they want to help and nothing changing that could drive me to contemplate suicide. So often we invalidate patients experiences, even when we don’t mean to. We’ll get you better. Just keep an open mind. Trust us. Why? Why should they trust a system that has historically failed them and only led to disappointment? Why are we acting like they are the one that is broken and they are only one more trial of SSRIs, one more session of group therapy away from being whole again? Yes these are proven therapies and in many case do work to help people manage their depression, but pills and therapy can’t fix the life circumstances that may have brought them there in the first place. This is just a half-baked thought and I’m not sure how to reconcile this. The way I approached it for myself today was essentially selfish and also in acknowledgement of the reality: I don’t want this person to die and we as a medical facility for better or worse have an obligation to keep this person from dying by whatever the means, i.e. we aren’t going to help them end their own life nor are we going to send them home in the state where they are likely going to end of their own life, even if it means holding them in the hospital against their will. So in the face of those realities, we might as well try something to see if it helps, and maybe keep expectations low.

The Fast Lane

Why is it so annoying when people zoom past us on the road? In general I wouldn’t call myself a road rage kinda person. I feel like I have a high tolerance for getting genuinely upset on when I’m driving. That doesn’t mean of course I don’t given in to the occasional cathartic expletive when drivers around me are being stupid, but usually I’m not actually angry. That said there is something about someone behind you switching lanes to drive past you even though it’s the person ahead of you holding you back that inspires so much annoyance. And then when they get caught behind a slower car you can’t help feel immense satisfaction at their misfortune, like a fat “I told you so.” (Even if I agree that the left lane should be reserved for active acceleration past cars and not for cruising and that the person up ahead is also a dumby).

But again why is it so annoying. Getting upset for people driving too fast or too slow is so dumb. Tailgating someone to make them go faster or get out of the way is so dumb. Driving 80 on the freeway with no one in your way will probably get you to your destination only a few minutes faster than if you drove the speed limit. Are you that pressed (I tell myself) that you want to endanger yourself and others by swerving past other cars and get yourself worked up how others are driving? As if those three minutes are going to significantly changing your experience after arrival (of course there are exceptions).

Don’t fuss over it. It’s not worth it.

TTITF
Light, but soft and warm throw blankies, ducks, fishing ponds

Internal Medicine – Day 22

Expectations are a huge part of medicine. Whether you’re are a provider, a patient, a student, a family member, or in any other role your expectations and whether or not they are met is a major deciding factor in whether or not your healthcare experience is a good one. In many cases, it seems like it’s the physician’s role to help manage expectations for the care team and for the patient. As a student, I’ve noticed it can be easy to get caught up in chasing lab values as an objective marker of a patient’s health improving. So much conversation and decision making occurs in the workrooms, unbeknownst to patients. Orders get signed, patients get sent of for diagnostics, or get their blood drawn without much shared decision making or conversation. I’m not necessarily saying that the patients need should be consulted before making every single decision, that would be impractical, but they deserve at the very least to know the plan before it happens or as it happens if possible. We need to set expectation so they don’t think we are poking them just for nothing, and when we think about it this way I think we become more mindful as to whether or not certain things are necessary. On multiple occasions, patient’s were getting their blood sugars checked unnecessarily, just because the order was placed in the ED and never canceled as they are transferred, until I point it out to my seniors or attending. Often times the patients have not expectations, so they just go along with it because they assume we are doing what’s best. Having conversations with patient about their care should be the standard. Managing patient expectations should be a part of their care, not an afterthought.

TTITF
Costco pizza, good public radio programming, innovative alarm clocks

Internal Medicine – Day 4-7

It’s been hard to keep up with these, but to be honest, in terms of experience, a lot of these days are more or less the same. I go in, rush to not be late even though I’m already waking up at 4:30 AM, starting looking at what happened to my patients overnight, start reviewing the charts of the new patients so I can decide which one I want to take, go get sign-out from the overnight docs, come back, do more chart review, go see my patients, start some charting, go on rounds, do more charting… wait I am just now realizing I went through all of this in the last post I think. It is interesting to see the different pathologies though, and to think about some of the more difficult etiologies of refractory problems. Also so far I feel like I’ve gotten pretty lucky with patients being pretty open to talking to me. I also feel like my Spanish is improving… slowly. Definitely been helpful to be hearing a lot of medical Spanish on a daily basis. I’m also learning a lot of other stuffy too.

We also got a new attending today. She’s little more formal, but also seems like we are going to have very clear expectations of us for this coming week. Wish me luck.

TTITF:
(1) Friends who talk to you about new things and make me think about things in different ways, (2) lasagna, (3) finding something you thought you lost forever.

Internal Medicine – Day 3

We had a substitute attending. Both the attendings I’ve worked with so far have been pretty young. Like late 20’s early 30’s looking. He was a super friendly guy with a very amicable and loose way of talking, as if we were his buddies and we were hanging at the bar. Except instead of beers we all had black coffee. And instead of sports, we were talking about anion gaps and how to spot right bundle branch block on an EKG. He put a lot of pressure on me when I was up to present my patient. He wanted me to read an x-ray and give a full assessment and plan for a patient, who I honestly had no idea what was going on. As we went through the presentation I maybe started to piece somethings together as processes were running in the background while I was speaking, trying not to repeat myself too much. When he actually asked for my assessment, I paused for a while, and stammered a bit, but eventually pulled a diagnosis out my ass, and he actually agreed. At first I thought he was doing one of those things where they just humor you at first as a teaching point and make you defend your case and describe your thought process even if you’re wrong. It felt good, and even for all the stress I had throughout the process I appreciate that he made me go through it and also didn’t make me feel too stupid when I said dumb things. Overall I’d say it was a good day for learning.

Internal Medicine – Day 2

I got my first patient today. History of pretty severe brain damage coming in for some generalize weakness. He was also in a pretty well-guarded and kinda hidden ward. I got lost trying to find it when I left the workroom to pre-round on him. And when I did I kinda followed some people who looked like they knew what they were doing, and then had to ask around cause the patient was not where our list said he would be. When I finally did find him, I wasn’t able to get much info between the language barrier (even with an interpreter) and the cognitive impairment. Fortunately he did understand enough (I think) to let me do some physical exam so I wouldn’t come back completely empty handed, though also just watching him move (he was feeding himself at the time) did also give some good general exam findings that I could report on. After that the day pretty much business as usual. Rounding then charting. My guy was pretty stable so after a quick consult, we were able to discharge him. My note was in and I was done. First patient, in-and-out.

It’s definitely a lot different here compared to family medicine. A lot of people talk about how crazy IM is, but to me, even in peds, it kind of feels like there is a lot of downtime compared to family medicine, at least from a student perspective. In FM, I was constantly doing something. Constantly alternating between seeing patients, to charting, to seeing the next patient when they were ready. No time to catch a breath in between. That said it is still early, and I don’t have the patient load of an intern (or even a sub-I) so that def part of it (but similarly in FM I didn’t have a full load). Yet why does it feel like there so much less time in the day?

Internal Medicine – Day 1

1 hour of orientation. That’s it. 1 hour for possibly the most time intensive rotation of medical school. On paper it’s 12 hours a day, 6 days a week. Thankfully it’ll be a little less than that most days if the residents are nice (though I feel bad because they actually need to stay the whole time). At orientation we just went through kinda of basics of the rotation, assignments, etc. and afterwards we went straight to the wards. I was excited because the person who was listed as my senior resident was someone I had met before volunteering and had run into a few times during the outpatient portion of my peds rotation. Super chill guy and was looking forward to being able to work with him some more. The other 3rd year on the team with me and I got a little lost on our way to our team’s work room but we made it. We met the senior and the 1st year residents. They all were super friendly and welcoming. It was a really good day, rounding with them, getting to know them. And then I find out today was their last day on the team before they switch to their next service… sad 😥

Overall though, IM was more or less what I expected. Very similar to in-patient peds, just a bit… older. But we spend the day reading out patients, then running around to see those patients and talking about them, then coming back to the work room to write about those patients. Since it was our first day, we didn’t get to have our own patients yet, but it was a good glimpse into how the team operated. Because of that we didn’t have much to do and that made it a little slow after rounds since there also were no new admissions. Thankfully, they sent us home a little early after the cutoff for new patients. Tomorrow is when it really begins.

Inadvertently Omitted

Sometimes when (if) I proofread what I write I notice that I will have completely left out whole words from sentences, words without which the sentence doesn’t make a lot of, at least in the absence appropriate context. I find that it happens most often when I pause to think. As if that word is a cliffhanger that never made it on the page, except there’s less drama and more confusion.

Language is a crazy thing. I’ve always thought of as separate from the various things that separate humans from other animals, but the more I think about it the more I realize it really just falls in the category of abstract thinking; our ability to believe in/ assign value to things that don’t have “concrete” existence (at least that’s my understanding of the concept of abstract thinking, please correct me if that’s not quite accurate [though saying such a thing reinforces the point I’m about to try to make]). Among other things in that category are money, religion, and crypto (which is like abstract-ception). These things have value because we say they do. There’s function and purpose to it of course, that’s why from an evolutionary standpoint it stuck around and helped humans be so “successful” in such a meteoric fashion. We use made-up symbols and sounds to communicate ideas about made-up things that we associate with tangible things, but only with people who believe in the same made-up sounds, symbols and things.

But these beliefs run so deep that even if important made-up things are we can still often make sense the idea being communicated, even if we are talking to someone we’ve never met before who just happens to share our abstract beliefs. Or in some cases we can even use a key or a decoder to relate our made-up beliefs to the completely different made-up beliefs of another person.

Or sometimes those symbols and sounds can be used to talk about something completely meaningless and non-sensical that only makes sense in the mind of someone who likes to talk about things he doesn’t fully understand.

Family Medicine – Day 21

My last full day in Family Medicine (as a medical student). And I was with a new doc. From what she told me, sounds like she’s relatively new out of residency and still building her practice. Her schedule did have a lot of Ob, peds, and new patients. I really enjoyed her style though. She was very autonomy oriented, as I hope to be, always trying to get a sense of what the patient had in mind as far as plan/ treatment/ what they would be open to before making her own suggestions. It’s not that the other docs ignored patient autonomy, but some encounters did seem like they were very much centered around numbers and lab values vs centered around the patient (not to detract from any of the docs I worked with, they were all amazing and showed their compassion and demonstrated patient-centered care in other ways).

Now I’m not sure if that is a product of her maybe being a little younger than the other docs, have to do with the fact that she had a more contemporary medical education relative to the others, or due to the fact that she may not be quite as far along on the jaded/ burnt-out scale compared to the others. Definitely wish I could have worked with her more.

I saw 2 fresh patients who were establishing with her. I thought I had done a good job of eliciting their health goals with their new doctor without injecting my own agenda. They both had a primary goal of weight loss. And I went through kinda the different options and approaches and seeing which they would be interested in pursuing and patted myself on the back for being so patient centered. But then my attending basically wrecked me after I presented the first of those 2 patients and was like, well did you ask to see if she had already done her own research and have a specific plan in mind as far as her weight loss? How could I be so dumb? The patient didn’t have a specific plan in mind, but I thought it was a good things to ask, and so I did with the second patient. She also had no idea. BUT STILL I think it’s good to recognize patient’s ideas and expectations regarding their healthcare and be able to address it even if you think whatever it is they have in mind is no recommended and you have to tell them that, because at least they will know that you considered it and care about what they have to say.

TTITF:
Fast internet, old keyboards, sticky notes

Sand Crabs

I always wondered why they were there. Why do they roll in with the waves just to burrow back down into the sand? Why don’t they just stay underground? Do they have to come up to eat? We used to catch them and feel them scamper around in our hands. I used to be afraid they would burrow through my skin. We would collect them in our 10 gallon plastic bucket and try to observe them undisturbed by the tumult of the tide, though perhaps more for sport than any investigative endeavors.

Interestingly at night, they don’t seem as eager to make their subterranean retreat. Maybe it makes sense because their predators may be asleep, but why even hang out? Is there more food? Is it cozy up on the surface? What is it is about nighttime that makes them so much more bold.