Midwife with a Knife

Family Practice is Dying (and it's not their fault)

2010-07-04T00:35:00.004-04:00

This is going to be controversial. I don't want to hurt anybody's feelings, but I do think that this is an issue that should be discussed.

Ok. Time for everybody to face reality. Family medicine as a "specialty" is dying. It's nobody's fault, but it's time to close the residencies and to redirect the medical students into other fields.

I didn't always think this way. I trained with some really amazing family practice docs because my ob/gyn residency also offered a family practice 1 year "c/s fellowship" so that family medicine docs could get cesarean section privileges.

However, what I've seen in the last almost 1 year as an attending at a hospital with a large number of fp docs with both ob and c/s privileges has changed my mind about the entire existence of family practice. Most of these docs, when they practice ob/gyn, don't really know what they're doing. They don't understand that a peripartum cardiomyopathy is a dilated cardiomyopathy. If a patient who had a baby 3 months ago has impaired diastolic relaxation, hypertension, and a low EF, that's not a peripartum cardiomyopathy. That's diastolic heart failure. That's a beta blocker deficiency in many cases. It's related to the patient's underlying severe chronic hypertension, not to their pregnancy.

They think it's appropriate for family practice docs to do complicated cesarean sections. Fourth and fifth repeats. Previas. They fail to refer moms with hemodynamically significant cardiac lesions to perinatology. They fail to offer 17 hydroxyprogesterone, or to send patients for a consultation to evaluate if they're candidates, when these patients have had very preterm deliveries.

There are a few docs who understand obstetrics enough to stay within their scope of care, but most of the family docs at our hospital go far beyond a reasonable family practice scope of care in ob/gyn (which should be limited to normal pregnancies). The problem is, their training in ob is just a few months (ok, maybe 6 months total if they complete the c/s fellowship which includes a lot of other stuff, it's marketed as a rural medicine fellowship). With that little training, they can't hope to have an appreciation for everything that can go wrong. I had over 1000 c/s under my belt before I graduated from residency. I did almost 2000 vaginal deliveries, 200 operative vaginal deliveries (prob about 100 forceps/100 vacuums). For a doc to think that they can do what a general ob gyn can do with about 10-20% as much operative experience is ludicrous. The answer then, would be for family docs who want to do ob/gyn to confine themselves to completely normal obstetrics, and arrange for an ob/gyn backup. The other problem is that there's no good compensation model for this, unless a procedure is required. Even then, in obstetrics, it's usually all about the global fee. So in some cases, the family practice docs risk loosing payment for the entire pregnancy if the patient is delivered by someone else. These global fees can get unbundled, but the person who provided the prenatal care invariably gets the short end of the stick when the fees get unbundled. Not only that, but malpractice costs can often provide a perverse incentive for FPs to practice outside of their scope of practice.

Once a doc's attentions are diverted to their entire practice and they're taking care of men, women, children, pregnant women, etc, maintaining competence within their scope of practice also dictates that they practice a very limited scope of practice. Physician training is so expensive that it may not make economic sense to train a bunch of docs who will then go on to have limited scopes of practice in several different fields. And while a lot of patients don't have complex medical needs (although many do), when you only have very shallow training in multiple fields, how do you know when a pregnant woman is sick? How do you know when a child is sick? It's experience that really allows people to see where the line between ok and not ok is and where you can really intervene and make a difference.

If people really wanted to have a limited practice and do well child checks and sore throats and uncomplicated hypertension and diabetes, that would likely be reaosnable but economically unsustainable. In any case, what I see are family practice residents who want to do procedures. They spend 6 weeks in Dillingham, Alaska doing colonoscopies. They ask if they can come do amniocenteses with me. They want to do my versions and operative deliveries with me. And I have to say "no", because these are procedures family practice docs should not be doing. The risk of complications with amniocentesis is higher with people who are less experienced. Version success rates are higher with more experience. And seriously? No family practice doc will be doing my next colonoscopy. Those are rightly in the hands of gastroenterologists who will be doing the treatment for abnormal findings. I suspect it is a search for higher reimbursement that drives these trainees to attempt to gain competence in procedures outside a reasonable scope of practice.

Now if we lived in a society that valued maintaining wellness as much as treating disease, well, it might be a different story. But even with respect to wellness, I don't think that the family practice docs would be any more effective at helping me loose my prednisone pudge (the almost 90 lbs I gained after 3 years on prednisone). I would be willing to guess that their scores with other types of wellness management would be similar to other primary care types (like internists and pediatricians). I do think that you do need to be able to spend real time with people in order to help them learn how to take care of themselves. Lecturing people about self control for 3 minutes is not helpful. Helping them learn what they can do to positively impact their health is helpful, but it also takes time that nobody in the US (including the patients themselves in many cases) are willing to pay for.

The advantage of the nature of training of family practice docs is that they have (if only brief) exposure to a wide variety of medical circumstances, which means that they may be even better than other primary care types (like internists) at quarterbacking the care of patients with lifelong chronic ilnesses, especially as they negotiate the transition into adulthood. However, this may not require visits, but it requires time in the office and phone calls (neither of which are things that our society cares to compensate doctors for because, you know, can't anybody make a phone call? *sarcasm intentional*).

So, the two natural niches of family practitioners, wellness and quarterbacking the care of patients with multiple medical problems, are not valued by our society at least in any monetary way.

But, attempting to extend their scope of care into procedures that are outside of a reasonable scope of practice for a fp doc will not fix this problem. I learned how to do appies in residency, just like anybody who operates in the pelvis does. However, if I get into trouble with an appendectomy or if I were to start an appendectomy and run into a different surgical problem in the abdomen, well, I just don't have the training for that. So I don't do appies. I leave them to the general surgeons. Doing c/s, colonoscopies, etc in an urban setting is simply deviating from the heart of what family practice is supposed to be. And the problem with doing them in a rural setting is that well, very few of the fp docs I know want to move to a rural setting (although those that do practice in a rural community without easy access to a tertiary care hospital seem to be exceptionally sharp), becuase well, no cable, no DVR, no ballet, no museums, no REI stores, etc.

For the record, a lot of the "scope of practice" stuff wouldn't apply to a rural area. If a patient needs a c/s and the local family doc is the only doc in.. .say... Coldfoot, Alaska I would want that doc to be able to do something. But in an odd coincidence, none of the "rural medicine" fellows are actually headed out to rural medicine. If they were actually going to go do rural medicine, I would have no problem with a more extended scope of practice, because even if they haven't had enough experience to be super skilled, they may still be the best option for many situations.

However, that's not the type of practice most family practice docs are training for. Most family practice residents are training for a practice model that doesn't actually exist in any compensated way.

Under Construction

2010-07-03T21:39:00.002-04:00

I'm updating my blog to better serve you!

(just kidding, it's actually because I want to).

First project is the blogroll.... but I am sorry if you don't find yourself over there. I think I have to update it by hand??

Not Dead Yet!

2010-07-03T20:01:00.002-04:00

Sorry about the extended absence. I've been reading a lot of your blogs, just not posting much. Why? Maybe not a lot to say, maybe getting used to being an attending (a "real doc", finally). Maybe a lot to do. Mostly, I was finding that time just slipped away from me, with one day melding into another.

When You Know A Bad Doctor

2010-02-02T17:36:00.002-05:00

How do you protect people from a bad doctor? Obviously if they're criminally bad, substance abusing, patient abusing, etc. and you are aware of the behavior, you can, and probably should, report them to the local medical board. Many states have ways to facilitate this.

But what do you do when you notice a pattern of practice from a doctor that is just not consistent with good medical care? When a patient who's baby has multiple birth defects is not offered an appropriate or complete workup? When patients are transferred to the hospital in an unsafe manner? When you know a doc is practicing outside their scope of care, or at least not practicing good medicine within their scope of care?

In the community I'm practicing in now, it's not that every other doc is incompetent. There are just a few, but the poor hapless patients end up in their care. And it seems like there's no way to protect them. Bad judgement, poor decisions are not prosecutable, and my area of the country has a low level of malpractice suits. Where I've been previously, these docs would get sued a couple of times and then practice gyn only or family practice without ob. But there's nothing I can do to protect the patients. Patients know when a doc is nice to them, but they have no way of knowing if their doc is a good doc or a bad doc. I can report people for illeagal behavior, but there's no way to report docs for being idiots. Obviously, I wouldn't send my patients to them, but there's a shortage of people doing obstetrics here, so some patients are always going to come to get their care with the Dr. Nincompoops.

This is Amazing

2010-01-07T17:51:00.001-05:00

My present to myself for completing my thesis was the new quad core iMac. OMG! I'm in love. I guess I'm going to have to become a mac person now....

It's been too long!

2010-01-06T14:46:00.004-05:00

OK, it's been a really long time. Sorry everybody!

In the meanwhile, though, I have finished my fellowship thesis and a couple of papers. For the last 3 months that's taken every ounce of spare energy and time left after work and sleep. Combine that with having caught giardia from the dog (and the colitis flare triggered by the giardia), potty training the dog, walking the dog, etc.

First, the pup-date! Zoe the puppy is doing mostly well. She is now ~60lbs (compared to 14 oz at birth) and is probably 1/2 of her adult size. She's had giardia, gave me giardia, and now has reacquired giardia from me (drinking out of the toilet IS hazardous!). She got spayed a week ago, and she's mostly healed but did manage to separate her incision in 2 places (~1 cm each). She's going to see the vet to see if we need to do anything about it. And she has dysplasia in her heel and may require little doggy arthroscopic surgery for it (or dogoscopy as my friend calls it!). That sounds like a lot of problems, and it has been frustrating because I really just want to play with her and teach her to do tricks and be a good dog and stuff, and she's been benched for most of the past month, but I think we're close to getting stuff resolved and by the end of January, everything should be fine.

Work's been good. Our office has moved into sweet new digs. I finally got all of my stuff framed for my wall so my office will look like a real doctors' office. I'm finally in a place where I can do my work and then actually leave it to go home or to martial arts class or doggy obediance class or whatever. I have to say, life after training IS so much better than fellowship or even residency (although I liked my residency). I think part of this is because I chose to become a private practice doctor. (more on the private practice/academic practice division later).

And, by the way, XE: you should invite me to read your blog! I can't access it right now. :(

Another Pup-Date! :)

2009-09-26T22:51:00.006-04:00

Here's Puppies!

2009-09-02T13:51:00.001-04:00

Puppies!! Mine is one of the black and white ones, and I think her name is Zoe. :)

Good Doc or Nice Doc

2009-08-30T22:09:00.004-04:00

I have now escaped the hospital (actually did it about a week ago). The whole 4.5 days I was there, all I really ever wanted was to go home. And I made no bones about it.

I showed up in the emergency room, and asked the ED doc for some iv fluids and some zofran, and told her that I didn't need any more than that, I didn't think, and that I would just leave. She offered me some narcs, I declined. She offered me a ct scan, I declined, and then she said, "will you at least please stay for some labs and for me to curbside gi on how to get you in to see someone before next februrary?", and I agreed. Then, she walked away, for a bit (she had sick people to see, I think), and came back just a few minutes later, and sort of laid down the law. She said unless I stayed for the abdominal ct (I think it was useless, but the ED scans pretty much everybody with tender bellies), the lab results, 2L of IVF, 2 doses of iv steroids, and a gi consult (she said they would come by at 7am), it would be against medical advice. So, I started to negotiate ("How about 1 dose of the steroids and I'll see the gi doc in a couple of days as an outpatient..."). At some point, the dilaudid started, and every time I tried to get my stuff together to go (or asked my nurse about some discharge papers), they drugged me again. Sneaky bastards. I do have to admit, I was quite uncomfortable, and dilaudid is quite effective for eliminating pain. I wasn't snowed enough to be considered "chemically restrained", but at the same time, you give 1 mg of dilaudid to someone who's essentially opiod naieve, and in addition to relieving them of pain, you will releive them of the motivation to sign out AMA, or really to leave at all.

The night was kind of bad. The ED just isn't a great place to hang out. Between the woman having an MI next to me and the lady yelling at the top of her voice, "bring me more dilaudid you f---ing c-nt!!", it's just not terribly restful, and everything that is annoying is more annoying when you're nauseated and having severe diarrhea. (dilaudid fixes that, too!).

Around 8 am I realized I wasn't going to be able to go home, and even if I convinced them to discharge me or to bring me AMA paperwork, I wasn't going to be able to work safely. I still was getting lightheaded and profusely sweating just walking to the bathroom, so I finally agreed to stay, and they took me to a hospital room. They actually hid me away on the oncology floor in a very tiny but pleasant and private room wiht a view of the ocean. The one good thing about UC is that if you get admitted to the hospital, there's always the possibility you could have C.diff, so you always get a medically necessary private room.

The nurses were extremely sweet to me. One brought in movies and books (that I was too fatigued to watch or read). They were very conscientous, and even went above and beyond the call of duty. In fact, my only complaint about the hospital is that the pillows suck. If I'd realized they were going to talk me into staying, I would have brought my own. For a couple of days, I felt too ill to concentrate on reading or movies, but started to spend more time awake. This is the annoying part of being sick. And I got so bored. I tried going for a walk, but didn't make it very far. Anyway, the nurses and aids would come in and actually chat with me. I felt a little bad about it, because I'm sure that they were busy, but I really appreciated it.

The gastroenterologist was, perhaps, a weirdo. I can't decide if he's a good doc or a bad doc. He sort of tread the line between being condescending and setting limits. Apparently he's the one that suggested the scheduled (as opposed to as needed) dilaudid (and it actually did slow the bathroom trips down a lot) that started in the ED. When he saw me the morning I was admitted, I told him that since I'd tolerated the ct contrast, I could probably go home on some oral steroids the next morning. I told him I really wanted to go to work, that it was a new job, and my first one out of training... blah blah blah. He listened for a little bit, but then stopped me, and said, "If you won't stay for 48 hours of IV steroids and until you're eating 3 meals a day on oral prednisone, then your gut won't heal, and we don't have anything else to talk about. " And he basically threatened to fire me if I left before his conditions were met. Now on one hand, I can see how he was probably right. I was a little anemic and a little dry on admission. On the other hand, well, he really was kind of bossy about it. On the third hand, I hope this doesn't mean that he's going to yell at me all the time as my doctor, 'cause I'm not into that. At the same time, he was, in other ways, very nice. I was explaining that I had been on prednisone for most of the last 2 years, never had a sustained remission, really, and that I'd gained like 40-50lbs on the prednisone. He told me, "Of course you did, almost everybody does, and we'll get you off the prednisone". And he told me a plan. And a plan in case the plan fails. And, aside from being bossy about staying in the hospital, he was pretty nice. And I guess, as a doc, I know that there are times when I just have to put my foot down to my patients, but usually it's about something serious, like the fact that they are putting themselves or their baby at risk of death by leaving the hospital. Not about the merits of inpatient vs outpatient treatment. So now I'm wondering how nice of a guy he'll really be. I mean, maybe he really did think it was vital for me to stay in the hospital? Or is he really a bit of a jerk? Everybody says he's the best guy for inflammatory bowel disease in the northwest, but nobody says he's the nicest guy around. At the same time, if he gets me feeling well consistently and off the prednisone on a long-term or permanent basis (without a colectomy), do I really care if he's a nice guy? I mean, nice is better than mean, but good is better than nice. My UC was, apparently been mismanaged by a pretty nice guy for a while, so maybe I should just be glad that I get to trade nice for good?

The rest of the hospital stay was the same. Too much dilaudid, too much food, which I forced myself to eat so that they would be sure to send me home. And the last week has been pretty good. I was home on Saturday, back to work on Monday, and I'm on call this weekend. The weird thing is? I feel so good now, I think I've probably been sicker for longer than I would have thought, if that makes sense. I haven't felt this good in maybe a year? Even the prednisone side effects, which are annoying (sleeplessness, increased apetite, weight gain, hot flashes), are worth it to feel this good right now.

Doctor as Patient

2009-08-20T13:55:00.003-04:00

So, I'm having a somewhat interesting experience right now. I ended up in the hospital. This was only partially my fault.

So, I've posted elsewhere about my ulcerative colitis. Mostly not a problem, except I've gained 40-50lbs on the prednisone I take for it. Or... took for it. So, given the weight gain, and the fact that every time I've gained a few pounds on it, I've been completely unsuccessful at loosing it, and because of the acne, I tapered and stopped my prednisone. 6 weeks ago. It went perfectly fine until 4 weeks ago. And although I'd started to get sick 4 weeks ago, I sort of figured that it might just get better (this really has never happened to me... but hope springs eternal!). And then, Monday, after having slept 40 of 48 hours this weekend, I realized something was really wrong. So I restarted my prednisone and made a gastroenterology appointment. They could get me in in 6 weeks. Um.. yay? So, I tried to keep on keeping on. Then tuesday night, I started having more abdominal pain and vomitting. Not tolerating even fluids orally is probably unsustainable in someone who has copious bloody diarrhea. I'm a doctor, there are some things I know. So after 6 hours of playing the rest for a few minutes, then try to drink, then vomitt, then rest gaime, I decided I'd go to the Emergency Department.

I figured I'd be in for some iv fluids, labs, some iv antiemetics, and then gone in time enough to make it to work on Wednesday morning. In fact, I came in saying, "I don't want to be admitted, I'm here so that I will be able to make it to work tomorrow morning. " I did get some labs, some iv antiemetics, a ct scan which I don't think I needed, and a couple of liters of normal saline (iv fluids) and some potassium. They admitted me, but only after giving me iv dilaudid and then convincing me to let them admit me. I do believe the ED doc, the hospitalist, and the gi on call were plotting against me this way. I feel as though tolerating the oral ct scan contrast was an adequate test of my ability to tolerate po. They say they will let me go tomorrow.

Some interesting observations:
1) the woman next to me in the ED was there for a chf exacerbation and had just eaten a ribeye steak, and had a blood sugar of ~500.
2) Lidocaine really does help when people are putting in IV's, especially those that are 18 gage or larger.
3) I wasn't super sick, but I was the sickest person (not counting the kids waiting for the children's hospital ED) in the waiting room. There were many drunk people and some with complaints that should have been taken care of as an outpatient.
4) I can't get a doctors appt as a new patient for 6+ weeks with a PCP. Faster if I torture myself by using my physician status to sneak in, which I refuse to do. So, maybe if some of the people who use the ED as their PCP could get an appointment with someone they wouldn't be in the ED. Of course, if they had established care when they should have, they would have a PCP by now.
5) Screaming, "You F&*king c*&t" is not a good way to get more pain medicine faster.
5) The hospitalist docs are nice. So are the nurses. So are the gi guys. They seem competent.
6) I think that dietary depts across the country are not designed to work well. I'm ordered for a low residue diet, but still, every day they offer me all sorts of salad and non-low residue things. If I didn't know what I shouldn't be eating (no salads, desserts ad lib, veggies and fruits should be cooked except bananas which are fair game), I would have a hard time.
7) My patients who complain about once or twice daily fragmin can suck it up. It's not that bad, and it's a damn site better than a dvt.
8) Although it feels like a disaster to call in sick to work, it really isn't, esp if you're really sick.
9) Good friends will feed the cats and bring pajamas and computers and movies
10) My siblings are more helpful than I have any right to expect.

More soon....

Time for a Pup-date! :)

2009-07-28T22:45:00.003-04:00

Hi Everyone!

Eventually, I will get back to medicine, I promise. Mostly, anyway. OK, well, some. The last couple of months have been kind of crazy, but in a good way. The events go as follows.

Middle of June: Graduation!
End of June: I defended my thesis and took my Maternal-Fetal Medicne boards. :)
End of June-Early July: Moved to west coast... 3000 mile drive with 2 cats and my brother.
Early July: Broke ankle (tiny itsy bitsy medial malleolar fracture) while jogging. I thought it was a sprain until it didn't really get better very quickly.
July 20: Started new job!
Tonight: First night on call for new job. It's amazing how much better this is than being a fellow, already. People care what I think. ?!?!? and I have input into my schedule!!

July 27: Puppy (pictured) born. I wonder how Bardiac knew. ;)

More Soon

2009-07-21T17:38:00.002-04:00

In response to Bardiac, and others, I still exist, but got distracted. :) I'll post more soon.

Luck sucks

2009-06-05T01:55:00.001-04:00

How is it on my very last call as a fellow I get a blood/body fluid exposure? Ah, well, low risk patient, and a scalpel stab is a pretty low risk exposure, but still.. I went 3 years without one, and now I get stabbed?

What if I don't Want to Multitask?

2009-06-04T16:21:00.002-04:00

Multitasking has been a serious fad (or perhaps gone beyond fad status...fadus?) for several years now. And I know I must be some sort of luddites (do luddites blog?), but I DONT WANT to multitask. Seriously.

I want to do one thing at a time, and finish that one thing and go on to the next. I don't want to talk to a nurse at the desk while I talk to the pharmacy on the phone and make a decision about the patient in the next room. I want to do the tasks in the appropriate prioritized order, because in my experience, multitasking leads to less good decision making.

And all of these little gadgets that let you talk on the phone while you drive or do laundry or watch dvds while driving? I actually don't like to talk on the phone while I drive. It's too distracting.

I was told during my internship that the key to being a good intern was multitasking. Well, I've come to disagree. I think the key is prioritizing.

Should I Join the Uninsured?

2009-06-02T10:01:00.002-04:00

A little dilemma... my health insurance through my current program will be immediately cancelled on June 30/July 1 at midnight. My COBRA payment would be $450. Clearly, one (even relatively minor) medical problem could cost more than that. I'm sort of strapped for cash these days (moving expenses, and all). I'm unlikely to need anything other than prednisone and the Lialda for my UC (ok, and I take some propranolol for migraine prophylaxis, but that's dirt cheap... so is the prednisone). However, a sprained ankle with an ER visit could cost >$1000.

Seriously, I plan on continuing my insurance. I can, however, see how some people make other decisions. And, outside of employer provided insurance, the ulcerative colitis would make me practically uninsurable.

Just some food for thought....

Homebirths

2009-05-28T23:46:00.004-04:00

Because I'm, you know, a high risk obstetrician, people even my friends, often assume that I'm against homebirths. Well, I'm not, exactly.

There certainly are a few disasters that can't be predicted, and may not be able to be treated in time to prevent maternal or fetal injury that we can deal with better in the hospital. But that list is pretty limited to catastrophic abruption, moderate to severe shoulder dystocia and umbilical cord prolapse. Sometimes, with these complications, there is no time to get to the hospital, and the baby and/or mom can die. And, to be honest, sometimes laboring in the room 10 feet from the operating room doesn't help with these either.

The other thing to remember is that these are rare events. Even in hospitals. Even in high risk populations they're uncommon. In fact, they're so uncommon that the statistics for perinatal death for homebirths are not any different (it's like if you have a 1/1000 perinatal mortality/morbidity rate and add to it a rare event, it doesn't increase the risk by very much. Even if you double the risk, that's not a big increase for rare events). And most of the complications of pregnancy and labor are things like arrest of labor or infection, and with those, as long as the midwife in question acts appropriately and gets patients to the hospital, there's time to treat. In fact, a recent Dutch study in BJOG was unable to find a significant increase in perinatal mortality in low risk women.

If you are a high risk woman, you should give birth in the hospital. Mostly because that's where the pediatricians are. Sure, fetal monitoring reduces the risk of neonatal seizures (but not cp) in high risk women, but mostly, infants of diabetic mothers, infants with growth restriction, preterm babies, etc. need to be in the hospital. If you've had a previous c/s, your likelyhood of a catastrophic complication of labor (uterine rupture) is high enough that you should give birth in a hospital, because timely recognition and emergency delivery can be lifesaving for infant and mother. And many, many other complications of pregnancy are best managed in the hospital.

But a normal uncomplicated pregnant woman wants to give birth at home? Sure, go for it! There may even be some (at least hypothetical) benefits to home birth: We have MRSA (that drug resistant staph you hear about on the news) running around our hospitals... if you can avoid exposing your baby to that, that's excellent. But please, if things start to deviate from the normal, please come to the hospital. We'll take good care of you and try to limit what we do to only necessary interventions, but interventions really are sometimes necessary (10% of women used to die in childbirth... and 30% of babies used to die before the age of 1).

As for me, well, if I ever have a baby, I'll do it in the hospital... for a few reasons. Number one, Having seen all of the bad stuff, I'd be too nervous to do it at home. Number two: um... having a baby is REALLY messy. If you deliver in the hospital, someone else cleans up. And number three? one word: EPIDURAL!!! ;)

But... just because I'm a wuss and want pain control and someone else to do the cleaning doesn't mean that everybody has to make the same choices I do. The only thing I worry about with home births is that there are a lot of lay midwives doing them. I've worked with some great CNMs, but lay midwives have no specific training requirements. So, check out your midwife carefully.

Transitions

2009-05-28T18:22:00.003-04:00

I'm on call, waiting for a c-section to go. My thesis is written (actually halfway through draft 2), my paper (about the thesis work) is also written, mostly. My presentation for my defense is done. What else to do, but blog?

You know, it's kind of funny. With fellowship winding down (IF they will ever let me defend so I can graduate...), I've been reflecting on the past.

Transitions are always an odd time. I've had plenty of them... you'd think I'd be used to it by now. But I think you never really get used to packing up your life and moving it halfway across the country. One of the weird things about medical training is that you have ~3-4 times you pack up your life and move sort of built into the training.

Anyway, this has me feeling kind of introspective, thinking about this and other transitions. I moved a lot as a kid. By the time I was in 9th grade, I had been in 9 different schools in 7 different cities, spread up to 5000 miles in distance. Thanks, BP! So, again, I should be used to this by now.

So, in some ways, this is like almost any move: Rediculously expensive, stressful (it takes a lot to get things organized to move me+2 cats), etc. But mostly, it's not like my other moves. Just a month into the fellowship here (back in August, 2006), I decided that these people were not very nice (the MFM division, not the patients... there are a few nice attendings, but for the most part, I'm treated worse here than I was as a resident), and that I wouldn't be staying. I flirted with an ICU fellowship and a PhD, but decided not to do them primarily because I don't want to have to be here any more. So, unlike most of my other moves, there's a sense of relief. A sense of "Thank goodness I can drive away on June 28 and it will all be over, and I'll never be under the control of those people ever again."

Also, this time, I have movers who are going to show up on June 27th and pack up all of my crap. I'm looking forward to that being a lot easier than packing it up myself, throwing it in a UHaul and driving it 2600 miles across the country.

However, the rituals of moving, the sorting through my stuff, getting immunization records, tb records, licenses, credentialling is so reminiscent of other transisions, it's just hard not to feel like it's happening again.

It's weird, sort of. My ability to get settled in this fellowship was hampered by the fact that I was still suffering the effects of a terrible incident from residency. Something I've realized wasn't really my fault, even if I was one of the primary 'dramatis personae', as it were. And, so I find myself feeling anxious. Anxious, partly because just the fact that I'm at another turning point in my life is so reminiscent of how terrible I felt the last time in my life I was in this place. And a little anxious because I keep thinking of that... that.. thing. (Although a little known secret... trying to not think about bad stuff doesn't help... but in a weird way, just letting yourself think about it kind of does).

And I'm anxious for all the normal reasons... will my new job be nice? Will people like me there? Will I like the people there?

Having said that, I'm not abnormally anxious, and in general, I'm really looking forward to working wiht and for people who will not (I hope) do things like cancel my defense 4 hours prior to the event, after I've already had to make an emergency call switch because they rescheduled it 4 days prior to the date..and then reschedule it ("with a 95% certainty") for 2 weeks away.

Sorry, another non-medical post. I guess I'm in a more personal mood right now. I'll get over it. Maybe.

(picture credit)

Seriously??

2009-05-26T14:32:00.001-04:00

They cancelled my defense so that they could entertain out of town guests. 4 hours prior. ARGH!!!

But thanks for all of the well-wishes everybody.

Whew and Wha????

2009-05-14T16:11:00.002-04:00

I just finished the first draft of my thesis (and have a firm defense date, scheduled, May 26th). I realize that the first draft is not going to be the final, and I have a bit of work left to do. It is, however, such a relief to have a (relatively) complete version finished!

And, because I've been doing a lot of "last things" recently, I did my last teaching conference (which we get paid a small amount of money into our 'educational' fund for). So, I went to buy a new laptop with the money. It wasn't a very expensive laptop ($800), just something that's lighter that will get me through until I start my real job (soon!!! Licensing is done, credentialling is almost done). Anyway, BestBuy tried to sell me a $500 extended warrenty. On an $800 laptop! If I had $500 to spend on an extended warrenty, I would just buy a new computer when the new one breaks.

Blogs Need Dogs

2009-04-26T20:42:00.002-04:00

Ok, maybe blogs do or do not need dogs, but I really really want a dog, starting with a puppy, and finishing with what the puppy grows up into. I think a Newfoundland would be the PERFECT dog for me.. intelligent, easy to please, sweat disposition... and to do water rescue training with one would be really cool.

I now find myself plotting on how to pick a place to live that will be dog appropriate and how to figure out what to do with the dog when I'm at work.....

If anybody knows any reputable Newf breeders in the pacific northwest, let me know!

Are You Reading My Blog?

2009-03-20T16:42:00.004-04:00

(I realize lemurs have nothing to do with this post, but I took this picture and thought these lemurs were adorable!)

I'm in Scotland (most of you already figured that out) at the annual scientific meeting of the SGI (Society for Gynecologic Investigation). Apparently after seeing that maybe I should have been a psychiatrist (on the previous post), they decided to take me up on it.

Today's symposium was on stress and reproductive dysfunction. So, it probably won't surprise anybody to hear that just like people have a range of height, they have a range of susceptibility to stress (as measured by basal cortisol levels). It also turns out that those people who are more stress susceptible are more likely to develop hypothalamic amenorrhea (loosing your periods because your brain stops telling your ovaries to ovulate), which is one of the major causes of infertility. It turns out when you have women with infertilty from hypothalamic amenorrhea (people we used to tell to exercise less and eat more), they get pregnant from CBT (Cognitive Behavioural Therapy). Or.. Rather... they get pregnant from sex, but CBT increases the odds, and restores their menstrual cycles.

And if you have certain stress susceptible monkeys (as defined by biologic assays performed when they're not stressed... they actually have chronically higher levels of cortisol), and you stress them out just a little bit (nothing dangerous... just moving them to a new room, for example), and make them exercise or diet, or expose them to more mild-moderate type stress, they'll get hypothalamic pituitary dysfunction related amenorrhea. And, if you give the monkeys citalopram (hard to do CBT with monkeys, they keep throwing feces at the therapists! ;) ), their cortisol levels normalize and their menstrual periods come back.

And although bedrest for preterm labor doesn't work, we probably feel like it does, because activating the CRH pathways in the maternal brain can activate them in the placenta and fetus... and people who live under chronic psychosocial stress (or who are socioeconomically disadvantaged) are more likely to go into preterm labor. When you put them in the hospital on bedrest, you isolate them from a lot of their previous stress, but when you randomize them to bedrest in hospital vs normal activity in hospital or bedrest at home vs normal activity at home, you won't see a difference.

The question then is, how do you talk to people about the fact that they're "stress susceptible" without making it sound like you're telling them that they're wusses? In fact, every time my mom says, "I think your ulcerative colitis is from stress" (Although certain forms of stress (certain aspects of work politics, not sleeping, etc.) make it worse, it is an immunologic/genetic condition) I feel like she's calling me a wuss. It's hard to refer someone for psychotherapy to treat their infertility without the patient getting the perception that you think there's something wrong with her... which, you probably do (you know, the infertility she came seeking treatment for), but not like she thinks (you (probably) don't think she's crazy, unless she wants you to transfer 6 embryos, in which case she DEFINATELY is crazy). Which, I guess is more a social stigma issue than a medical issue... although social stigma IS a medical issue. Becaue medically, I think the best I can do is to say, "We know that people with this type of infertility respond well to psychotherapy/antidepressants/nap time/whatever, and that's definately less invasive than IVF/ovulation induction, so I think we should try that first." I think you also have to have a psychotherapist that sort of expects these patients to come to them from you.

If that makes any sense....

I should have been a psychiatrist?

2009-03-18T11:04:00.002-04:00

OB/gyn is down there at #26 or so, and perinatologist isn't on the list (it may not be one of the specialties on the test).

#1-10 in order were:

psychiatry (I'm not sure I really like talking to people this much)
general surgery (almost did a gen surg residency at one point)
occupational med (no way!)
ortho (ok... it always looked fun)
GI (erm... ok..)
colorectal surgeon (kinda like gen surg, so ok..)
urology (ok.. I could see this procedure oriented patient care specialty)
preventative medicine (is this really a specialty?)
radiology (not that fond of dark rooms, actually)
neurology (Um... I like for my patients to get better, thanks. Not that good with diseases that don't go away.)

I'm not sure how I answered the questions wrong, but it seems like there isn't even a consistent theme in my results. Try it yourself at: http://www.med-ed.virginia.edu/specialties/

I remain convinced that the real way to choose a medical specialty is to try out different stuff until you find something you love. There really is something for everybody from radiologists to psychiatrists, from preventative med (still not sure if that's a real specialty) to perinatology. But I'm not convinced this quiz will help you find it.

Thank God Someone Speaks American Around Here!

2009-03-18T09:13:00.004-04:00

So, I actually made it to the meeting today, kind of. Long story short, I thought today was the 19th, and I'd signed up for some of the courses on the 19th (I didn't pay for any of the postgraduate courses, you know, the kind that cost $200+ for a single day of class). Anyway, I've gotten back into jogging (was out of it for 2 months because of a bad ankle sprain), but maybe overdid it a tiny bit (Glasgow's hilly! The midwest is not!), and have been a bit sore (esp in the iliotibial band type area). Mostly I just tell myself to suck it up because pain builds character (or whatever), but found myself feeling grumpy, so I decided to buy some acetomenophen/tylenol.

Stopped into a pharmacy (apparently all drugs are behind the counter here), asked for acetomenophen and tylenol (trying to think... now what else is this stuff called?), and the lady behind the counter was looking confused (but wanted to help). Someone yelled from the back, "That's American for Paracetamol!"

Hah! I was afraid I was going to have to ask for "something for sore legs" and see what they offered....

Seriously?

2009-03-17T15:37:00.002-04:00

A sunburn? In Scotland? In MARCH??

WTF. I usually wear sunscreen every day (because I burn pretty easily and have lost most of the skin on my face and back and back of my legs at one point or another to blistering sunburns. Always surprised they don't scar). I forgot to bring it with me, and figured... "eh... it's March, it'll be ok", and now after a day out in moderately sunny weather, I'm feeling that post outing mild-sunburn warmth and redness in my cheeks and across my nose.

Note to self: buy sunscreen!

Thank you, Trooper

2009-03-16T01:44:00.004-04:00

I'm doing a lot of traveling right now. I was out on the west coast earlier this weekend, and now I'm here, in Amsterdam, headed to Scotland. Lots of work to do, too. On Friday night, it all caught up with me. I was driving back to my hotel (nearish to the airport) from my mom's house (150 miles from the airport). I had given 2 hours of lectures at a conference, and hopped into my car to go visit my mom, who lives... well... 150 miles north of the conference venue.

Add the cumulative exhaustion of 11 years of medical training to the traveling and the conference giving, and well, I was exhausted. But my mom has had a rough time, and she needs to feel like people care, I think. So, I went to see her. My plan was to go, get there and leave by 630-7pm. I got there, she and my aunt wanted to go for appetizers, but they really kidnapped me into a full dinner. (Remind me to get better at setting limits with and saying no to them.), so it was 9-10pm by the time I was leaving town. I started the trip out tired, and I remember at one point thinking about whether or not I was too tired to make it down to the hotel, or if I should pull off and get some coffee or something and rest for afew minutes. Well, that would have been good, but before I could make that decision, I saw the police lights in back. At first I thought it couldn't have been me, because I was driving well below the speed limit...

They were after me. The officer said that I was changing lanes and braking erratically (How embarassing is it to be pulled over for suspected drunk driving only to be sober?). I didn't really remember that. After talking to the state trooper, I must have been driving pretty badly. I think I fell asleep while driving. He didn't ticket me, and the adrenaline from the traffic stop pretty much woke me up to get the rest of the way to the hotel (~15 miles).

In retrospect, he may have saved my life (or more importantly, kept me from killing some poor innocent people). I really appreciate that. Next time, I need to have the guts to tell my mom that I'm too tired to drive 300 miles round-trip. And in the future, when I feel that tired and sleepy, I will pull over before putting anybody else at risk.

(image credit)

A Submarine... With Donuts?

2009-03-16T01:25:00.002-04:00

Greetings from Shiphol Airport, Amsterdam, where I am sitting, during a 4 hour layover, on my way to Scotland. It's a very circle-ey place. It reminds me a bit of a submarine... with donuts. :)

On Healthcare Reform

2009-03-09T14:11:00.003-04:00

(My VBAC post is getting written, but I just have a few minutes, and this post only takes a few minutes).

To me, it seems very wrong that our office pays $260 for an interpreter for 45 minutes to see a patient. It's wrong because the visit which I just saw the patient for is probably non-reimbursable, and if it's reimbursable at all, the reimbursment will be <$100.

I actually don't think it's a bad idea for docs to see patients for free... but who can afford to donate their time plus $150-$260 for any real fraction of their patient population. These things aren't tax deductable, yet we're madated to meet the needs of people who can't speak and understand English. Why is it the docs are required to donate their time and money while the sign interpreter donates nothing?

I can see why private practice docs don't see patients like this. If I were in a real private practice, I too might be forced to tell these patients that they should go to the local university hospital because I would be unable to meet their needs (unable to meet their needs and still pay my staff, that is).

If people are serious about healthcare reform, this is a problem they should tackle.

On Service

2009-02-16T03:06:00.004-05:00

I've been a bad bad blogger. You know, work, etc. Now, I'm awake at 3am because of night sweat/fever induced insomnia and I find myself actually hoping I'm catching a cold. Because the other likely alternative is that the colitis is back after months of pretty good control on 10mg of prednisone (which induces its own insomnia, but one that's treatable with sleep hygeine and Ambien (tm) and more or less mild at this dose). And I often will have a flare when I work a lot of hours, and I've been working from 6am-8pm most days of the week this month (except when I'm on call in which case it's usually like 6am-2pm the next day)

Anyway, in response to Bardiac's question, being on service means being the fellow in charge of the MFM inpatient service and outpatient clinics. Generally, we also work with a group of residents (my residents are awesome!) as well as a supervising attending. Most attendings will let me have the autonomy to manage the patients how I want (within the standard of care), however, I'm stuck with an extremely anxious attending for the inpatients who freaks out all the time and yells at the residents (which is at least better than her yelling at me?), and so I make a lot of effort to anticipate what she would want to do and plan to do things that way (a month-long game of "guess what I'm thinking") so that she doesn't feel threatened or nervous and freak out and yell at them (or me... but mostly she yells at them). I know, I don't have to do that, but I really HATE it when people yell.

The other attending is a brand new attending (so new that she will be taking her board exams with me in a few months) and she doesn't trust anything anybody does. Including me. So, every time someone presents a chart to her, she hunts through it to make sure that there's nothing else. Probably good patient care, but #1: She can trust me, and it doesn't feel good when she doesn't (and micromanagement is bad leadership) and #2: it's not good patient care to cause such long delays... patients walk out without being seen.

So, because we have to round early enough to get everything done before clinic, we start at 5:30am-6:30am, which makes for really long days, because the residents will then have stuff to finish up on the inpatient service after the clinics end at 6pm. I think this is not compliant with their work-hours, because they also take call on the weekend, so my guess is that they work ~100 hours a week with only a couple of days off. I worry that after being yelled at (by attending a) and not trusted (by attending b), they will not like MFM, and that would be a shame, because perinatology is fun. And because, ultimately, we need a steady supply of perinatologists to replace people who leave (retire, etc). And scaring otherwise good residents away is not a good strategy for the continuation of our medical species.

The residents, however, are troopers, and are taking the yelling from a and the micromanagement from b in good graces. And now we're all halfway done with the month. Hurray!

So, anyway, being "on service" means being responsible for the care and feeding of 2-4 residents (for me, 3) , a variable number of medical students (right now 0, because they don't want to do the month with these attendings... wise choice), and responsible for making plans for high-risk pregnant patients. It's usually a good month, but right now, it's complicated. And at least it's half-way done.

Just Passing Through

2009-02-09T02:41:00.002-05:00

I've been in San Diego for a conference for a week (end of Jan), and I'm headed to Scotland next month for another conference.

I'm on service for the next 3 months (and last 3 months of service of my fellowship! Yay!).

More soon.... I can't decide if I should post about resident work hours, the care and feeding of interns, or some more obstetric topic (vbacs, etc.). I don't plan to talk much about the octuplets except to say that that woman's infertility doc should be beaten with a wet noodle.

I'm a Tool (or 5.5 Months Until Graduation)

2009-01-13T17:43:00.005-05:00

So, the program that I'm at primarily regards its fellows as tools... Tools to get vaginal swabbing done. Tools to help with the call schedule. Tools to do the resident education for obstetrical topics, etc.

Our education is such a low priority that there has not been an MFM fellows' lecture series. It's such a low priority that when there are interesting grand rounds or speakers, the attendings will often expect us to cover their resident protected time or clinical activities so that they can go. I try to give them a little slack, because they only have 3 MFMs (for 5700 deliveries and an ultrasound unit).

Our education is such a low priority at this institution that I'm essentially a self-taught MFM.

It's kind of a malignant place, in a lot of ways. They've totally broken the educational social contract of graduate medical education. You know, the understood bit about us helping out the department and attendings at a very low rate of pay (~$46k if you want to know) in exchange for education? Our educational needs/wants are dismissed under the guise of "Learn to be an independant life-long learner!". We can get called in on no notice for a 10 minute meeting on a Saturday that has no identifiable purpose other than to prove that we had a meeting.

Having said this, the most recent event takes the cake. It is no surprise that we are required to defend our thesis prior to graduation. Ok... whatever.

But imagine my surprise when I get an email one night that says basically, 'Your defense is in a week' (apparently that was a convienient time for the attendings). So, I spend 24 hours in a near-panic, until I get an email that says "Oh, never mind, it's in May....".

Now, I just need to manage not to quit for long enough to graduate!

You know, the people here seem to think I'm a disappointment because I didn't choose to go into academic medicine. Had my experience here been better, I might have stayed in academics.

In all fairness, the department has deteriorated to this level likely as a result of the demoralization and burnout of the few remaining attendings. I don't feel that this is an excuse for creating an environment uncondusive to learning, but it is probably the main factor.

For all of you looking at training programs right now, my advice is this: STAY AWAY from programs that don't have enough attendings to do the work!!

More Later

2009-01-06T21:58:00.001-05:00

Happy New Year and Happy Holidays everybody (whichever holidays they are, I hope they're happy!).

I just wanted to say I'm not gone, or rather... I'll be back. I have my fellowship thesis defense in a week, so I'm drowning right now.

Wish me luck?

BRRRR!

2008-12-07T12:04:00.003-05:00

I'm trying to work up the energy/courage to go outside and jog, but the windchill out there is 2 F right now, so it's difficult! I would just skip, except it's Sunday, which is one of the easiest days for me to find the time to exercise!

(image credit)

Obstetric Psychiatry and Ethics?

2008-12-03T18:00:00.005-05:00

For the first time ever, today I had to seek legal appointment of a guardian for a patient who couldn't make decisions for herself. We commonly consult our psychiatry friends with a question that goes something like, "This lady seems really not right, she wants to [leave AMA, refuse surgery, whatever], could you come make sure she's competent to make that decision." when patients seem like they're impaired and making poor decisions (although oddly (or not) we don't tend to question when they make good decisions).

Generally, the psychiatrists' answers go something like, "Well, she does have a history of [insert garden variety mental illness here], but she isn't too impaired to make her own decisions. And everybody has the right to make bad decisions." Which is true. I had every right to leave the ambulance AMA a couple of years ago. I had a skull fracture, it was a bad decision. But it was my bad decision to make. And you could argue that someone with a recent (say 20 minutes old) head injury with loss of consciousness may not be competent to make their own decisions. And I'm still glad they didn't make me go to the hospital.

So, we had a patient today with a history of conversion disorder (diagnosed after diagnosis of her present pregnancy after a long hospitalization), who actually now is sick with severe preeclampsia/toxemia. She needs to have her baby, but having had 5 previous c-sections, she needs a c-section to deliver.

So, she tried to leave AMA, but stayed for a psych eval. The psychiatrist said that she's not competent, suggested some haldol, and wrote a diagnosis which I can't read (typical doctors' handwriting! ;) ), but I think said something about psychosis, which makes sense, because at times, this patient seems almost delusional (thinks we can read her mind and forcast the past (I know, doesn't make sense to me either).

So, a couple of thoughts. First of all, it's got to be totally scary if your brain doesn't work right, and you have a really dangerous complication of pregnancy and are facing delivery at 30 weeks.

Second, I'm going to go deliver her baby tomorrow. During this admission, but before she seemed delusional, she signed for a tubal ligation. My medical recommendation would be that as this is her 6th c-section, she should have her tubes tied. Should we tie her tubes?

Thirdly, do you tell her she's been deemed incompetent? When I was there, we were skirting around the issues, and managed to get her calmed down enough to give her treatment for a few things (her blood pressure, monitor her baby, treat her headache, and give her the haldol the psychiatrist suggested (and some ambien is planned tonight because she hasn't slept in the 5 days she's been at the hospital. That might cause some psychosis in even the non-mentally ill, I might think!).

(Ethics consult/court signature for her mother's role as guardian/etc. is all taking place nowish.)

(image credit)

This Blog Has Been Temporarily Interrupted

2008-11-23T16:36:00.004-05:00

Blogging has been temporarily interrupted by the purchase of Call of Duty: World at War. Blogging will resume when the Japanese surrender.....

I Wonder...

2008-11-15T21:14:00.002-05:00

Would my gastroenterologist think I'm nuts if I tell him that prednisome makes me able to feel my heart beat (it's like feeling your pulse all over my body, even my toes)?

It's a nuisance, but only a nuisance. I'm not tachycardic and my heart beat is regular. And when I distract myself I don't notice it nearly as much. No chest pain or anything, so I'm pretty sure nothing dangerous is going on. It just all falls under the category of prednisone side effects that annoy me (along with migraines, "water retention", insomnia, irritability and increased apetite (I think I'm rejoining weight watchers next week)). And while he never didn't believe me me about the other prednisone side efects, this complaint seems a little crazier than the others. The other issue is that insomnia and migraines can be easily treated (so can water retention, but I don't want to spend more time in the bathroom). While there's no great medicine for irritability (well, there might be, but I'm not interested in anything that will make me sleepy), treating the insomnia helps a bit with it, and so does trying to arrange my life so it's less irritating. (see below)

Thinking of treating... because constantly feeling one's own heartbeat can be distracting and annoyin,. I've surruptitiously tried a little bit of a beta blocker for it (just 10mg of propranolol... really a baby dose), but I got symptomatic orthostatic hypotension (meaning I felt so faint when standing up that I couldn't really stand, likely from a sudden drop in blood pressure) (in retrospect, since my baseline blood pressure is 100/60 and my baseline heart rate is in the 60's, it makes sense that I might be a little sensitive to beta blockers). [Note to self: just because I CAN self-prescribe doesn't always mean that I SHOULD self-prescribe. My body is not a science experiment...]. My friend tells me I should get a hemoglobin checked, just in case, but first off, I don't think it's an anemia thing because I have no problem exercising (it's distracting enough that I don't feel the heart beat thing), and when my hemoglobin was 8 a few months ago, I wasn't able to exercise. Besides, I'm not going to let anybody transfuse me right now (I'm not sick enough to need it), and I already take iron, folate and B-12 supplements. Therefore, if my treatment plan isn't going to change, there's no point doing the lab test.

(image credit)

What Is a Perinatologist

2008-11-12T00:07:00.003-05:00

I am sitting here writing this post waiting for a c-section to go back. It's midnight. The c-section isn't anything emergent, it's just a woman who thought she wanted to have a vaginal birth after cesarean but changed her mind 10 hours into the induction (she's not even in labor!).

So, Xavier Emmanual asked what a perinatologist does in the community and if there's a possibility for a reasonable life.

According to Wikipedia (my source for all matters factual :) ), Maternal-fetal medicine (MFM) is the branch of obstetrics that focuses on the medical and surgical management of high-risk pregnancies. Management includes monitoring and treatment including comprehensive ultrasound, chorionic villus sampling, genetic amniocentesis, and fetal surgery or treatment. An obstetrician who practices maternal-fetal medicine sometimes is known as a perinatologist. This is a sub specialty to obstetrics and gynecology mainly used for patients with high risk pregnancies.

So, for example, we help to manage (either as the primary obstetrician or in consultation) pregnancies affected by things such as lupus, diabetes, higher-order multiple gestations and twin gestations, as well as diagnosing and assessing fetal anomalies.

In a community hospital, we still do all of those things, if there is a Level III NICU available (which there will be in the job I'm going to). My scope of practice would be more limited if I went to a hospital without a level III NICU, which is why I didn't consider any jobs like that.

In terms of schedule, most of what happens on labor and delivery can be cared for by most competent general obstetrician-gynecologists. I also believe that in this day and age, nobody should work for 30 hours continuously any more. My schedule will involve home call (where I have to be within 30 minutes of the hospital for consults or to assist on complicated surgeries), 3-4 days per week of clinic, and 2 days/month of administrative duties in maintaining the regional perinatal network and some educational duties. Perinatologists are in high demand, and hospitals have started realizing that perinatologists are also a little lazy, and don't want to work 120 hours/week, particularly after having worked that schedule for 11 years already.

So, the role of the perinatologist in the community (assuming it's at a tertiary care hospital) is the same (except no research, usually). The schedule is well... an obstetricians schedule, but since we're in high demand, one can decide what they're willing to do, and find a job that allows it.

I hope that helps! :)

(image credit)

I'm Leaving (the Ivory Tower)

2008-11-09T19:48:00.004-05:00

I've returned from a bit of an exile from blogland. I was busy finishing up my job interviews (it's amazing how exhausting that was), I was then busy at work (still am.. but it's eased off a bit), and then I did a few weeks of Q2 call (paying people back who covered for me while I was interviewing). I spent this weekend recovering. And whining about the UC flare triggered by the complete lack of adequate rest for the last 1-2 months to anybody who would listen.

And, interestingly enough, I kept coming back to accepting the first job I interviewed at. It's in a lovely part of the country and the people there are nice. My best friend is a doc at the hospital (not an ob-gyn type though).

So, here's the thing. It's a private practice type job. In a huge multispecialty group. In a delightful area of the country. And everybody at work tells me, "you're too good for private practice." What does that even mean, exactly? Academic medicine has a certain amount of prestige, it's true. And I really do respect those people who can be awesome clinicians and amazing scientists. However, to do both successfully takes a huge time commitment. Those who aren't willing to make the huge time commitment are (generally) either sub-par clinicians and great scientists or sub-par scientists and great clinicians. At this point in my life, I don't want to spend so much time to be a mediocre anything. I don't want to be writing grants in my spare time. I'm actually looking forward to having a 4-day/week work week. I'm looking forward to taking call from home and only coming in for patients with whom I have a relationship or for patients who are so sick that they need me then and there.

I'm just not willing to make the academic medicine time commitment right now. On one hand, it feels a little bit like a concession to the UC. Part of the reason I took a private practice job is the fact that I have to be in control of my hours, and I can't work for 30+ hours in a row on a regular basis and continue to feel good. I don't want to spend my weekends off writing papers and grant proposals. Most of the academic centers I've interviewed at are still operating in that model where you work all day, cover L&D all night, and then work through the next day. I have no interest in doing that any more.

Also, this is a great excuse for me to get a life (which I haven't had for years).

I'm looking forward to this job. It involves serving an underserved population and involves some public health activities, which I haven't ever known much about but I am interested in it. I'm actually fairly certain I made the right decision.

But I still feel a little guilty for leaving "the ivory tower".

Having said all of that, it's still good to be back.

Image credit

I'm OK!

2008-10-11T15:35:00.001-04:00

Hi Everybody! I've got a few comments in the last few days from people hoping I was ok. I'm fine, I'm just super busy, but it warms my heart to know that y'all miss me when I'm not around.

More later/soon...

I'm a Lazy Slob!

2008-09-06T18:42:00.003-04:00

My house is a mess, my life is a mess (too long since I've paid bills), I'm behind at work (too much time traveling and interviewing for jobs), I think even my cats are feeling neglected.

My plan for today was: Jog, get drug test for new job (starts in July), go to tae-kwon-do class, buy groceries, clean house, do laundry, go to work for 6-8 hours, write checks for bills.

What did I actually do? Well, I went to get the drug test, the place was inexplicably closed, despite their posted hours of 8am-12pm. I bought some groceries, I went back to see if drug test place had opened (still closed), and I went home and napped. Woke up, went to the bagel shop for a sandwich for lunch, came home, watched bad tv, took a nap while cuddling with the kitties, got up (intending to go for a jog), watched more tv, talked on the phone, perused blogs.

I could make plenty of excuses (like I had pneumonia! I pulled a muscle in my back (I think it's my lattisumus dorsi), but the truth is? I just didn't feel like doing anything. Just like I don't feel like turning my groceries into dinner (not really hungry), and right now, I almost wish it were 9pm so I could just go to bed.

I feel like such a lazy slob.

But I will try to do better tomorrow!

An Apology to the Medical Students

2008-09-03T17:58:00.003-04:00

Dear Medical Students,

I'm very sorry for the lecture I gave today. It was supposed to be about prenatal diagnosis. Yes, I was vaguely aware that I was drifting off and talking about cars, and making bizarre references to cheese in my near sleep. I am aware that I was finishing my sentences in completely uninteligible ways, and all I can say is that I was too exhausted to be lecturing.

I was on call yesterday, and I got utterly destroyed, and the period of time I sat down to give the lecture was the first time I'd sat down in more than 24 hours.

I usually don't send out my powerpoint slides (people have stolen pictures from me in the past), but I'll send them out this time, because when I'm actually falling asleep while trying to give my own lecture, I feel like you need a little help. To your credit, none of you actually fell asleep during my lecture, but that may have been because it was a... unique.... experience.

Oh, and I may reevaluate my position on God and whether or not he takes a personal interest in my life, because despite a level of exhaustion that made me unable to give a lecture without falling asleep while speaking, I managed to drive home safely. That suggests a level of poor judgement on my part (maybe I should have taken a nap before driving home), and possibly some sort of divine intervention on my behalf.

Sincerely,
Me

Maybe I am a Bad Patient

2008-08-29T12:18:00.004-04:00

I have been doing a ton of traveling (for job interviews), some trips with plane flights in the 7-10 hour range. A couple of nights ago, I was unable to sleep because I was really short of breath. I had some fevers, some pain over my right chest wall. I had had a cold, which was almost gone. Other than that, I'd been pretty healthy, recently. Continuing to wean the prednisone, feeling strong and tough.

And now this.

Always being one to avoid actual medical care, I dragged one of the residents into my evil plan. "Hey, resident," I said, "I've had a cold, and I just feel a little funny. I'm headed home to bed, but I wanted to check my O2 sat first, because I'm a hypochondriac and it'll make me feel better, do you know where the pulse oximeter is?". The helpful resident was well, helpful. However, we got busted by one of my attendings, who kicked the resident out and yelled at me. "What are you doing? Seriously, you're on chronic steroids, you've been on long plane flights, if you're short of breath you absolutely need a work up. You could have pneumonia. You could have a PE!"

My response was a rather weak, "Well, I'm just getting over a cold, I figured I was just being a little hypochondriacal, and imaginging the shortness of breath." So as it turns out, my O2 sat was 96% (not terrible), and my pulse was 118 (a bit fast). My attending listened to my lungs, decided something wasn't right (crackles and rhonchi on the right side) called my primary care doc and um... told on me. My PCP made me promise to go to the emergency room.

In the emergency room, I had a chest x-ray, an albuterol neb (which did almost nothing except make me tachycardic to the 150's and shakey), some blood work. They were quite nice to me, although I ran into a couple of the interns, and I was too short of breath to explain why I was there, so I'm sure there's all sorts of rumors going around.

The verdict? A right middle lobe pneumonia. I have no idea where I would have caught pneumonia. I haven't been doing much patient care, just a lot of traveling. Some doxycycline (which isn't something I generally think of for pneumonia, but it should be a good antibiotic for it), some codeine cough syrup (which also helps nicely with the pleuritic chest pain), and some rest. Actually, a lot of rest. Every 20 minutes awake seems to result in a 1 hour nap.

So, yes, it was wrong of me to involve the resident in my evil plan. And I did deserve the lecture from my attending. I continued to actually get sicker over the first ~20 hours after I got out of the emergency room. If I had waited much longer, I might have ultimately been sick enough to need admission, and I'm not into hospital admission.

In my own defense, I actually don't really know at what point I should worry about these things. And my assumption is usually that I'm actually fine, just a little hypochondriacal.

(image credit)

Ecuador: Days 4-9: Clinic

2008-08-28T00:08:00.009-04:00

I'm not dead, not yet, anyway. ;) Thanks for your concern, but I really have been just super busy, off interviewing for jobs and going to conferences and stuff. Over the last 2 months, I've spent less than 2 weeks at home. Traveling is getting tiring!

So, anyway, the real reason I was in Ecuador! I'll start off by saying that initially I thought that the reason I was going to Ecuador was to take care of the people. And I did some of that, but as it turns out, I was a little mistaken.

Our clinic was in a little town called San Martin, in the mountains above Quito. Having arrived from near sea-level at Banyos the night before, I spent my first day in clinic being somewhat useless and dizzy. I wouldn't say I had altitude sickness (or acute mountain sickness to be technical about it), it was more a matter of needing more than 8 hours to acclimatize to the 14,000 foot altitude.

Anyway, it was me, 2 other docs (family medicine people) and a whole cadre of Spanish-speaking med students. I have to say, initially, I felt completely useless. Most of the patients complaints were things I had treated only long ago (if ever). Kids with parasites, old women with rotator cuff injuries. Men with BPH. That kind of thing. Kids with other problems. A kid with Henoch-Schonlein purpura.

Then I realized it. The real reason I was in Ecuador was to teach the medical students how to take care of people. That realization (and maybe actually becoming acclimatized made a huge difference).

Some other observations: The reason docs like to go to the third world to help out is the fact that you can do a lot with very limited resources. All of our meds, all of our equipment were donated. It cost some money to ship the stuff (and the team) down, but basically, we helped people in ways we would not have been able to in the US, simply because the legal system (and JCHAO) have made things so expensive. Patient expectations also add to the cost. In Ecuador, people are willing to accept some ambiguity of diagnosis and try a treatment to see if it works. In the US, if you tell someone, "I think you have x, but there is a small possibility you could have y, so we're going to try to treat for x, and if it doesn't work, we'll need to rule out y", they really want the ct scan or blood work or whatever to rule out disease y.

Interestingly, Ecuadorians don't expect perfect health all of the time. They don't expect their babies to be perfect (they're aware of the risk that things happen, and they're grateful when their babies are normal). They don't expect to be pain-free all of the time.

Having said that, Ecuador does need more trial lawyers (the US has too many... maybe we could ship some down there?). People have horrible work-place injuries (like blindings) and get either no or minimal compensation, often not even enough to pay for medical bills.

Ecuador is a dangerous place. They don't seem to think about safety much in Ecuador. This is why they need more trial lawyers. People to sue the pants off of people when they're a bus driver and drive drunk and end up in an accident that paralyzes some poor kid.

You can practice good and rewarding medicine in a building with a dirt floor and without indoor plumming.

There are some illnesses that are really difficult to treat without any real way to follow the patient up (the clinic's only open for 2 months).

I guess that's most of it. I'll close with some pics.

The road outside our clinic

Our waiting room

The exam rooms, separated by sheets hung from string

Washing out a little girl's ear

History Taking

A happy patient!

Curious

2008-08-03T18:57:00.002-04:00

Could someone please explain to me why prednisone makes me have more migraines?

And while you're at it, please tell me why mowing my lawn seems to consistently trigger them? I'm not suffering terribly, I mean, I'm not getting as much work as I'd like to done right now, but I have good drugs (Relpax (basically a long-acting form of Imitrex) works well and doesn't make me sleepy (although the headache sort of gives me the urge to rest in a cool dark room)). But it wasn't too hot outside (hm... maybe 80?), I did get a little sweaty, but not dehydrated.

I'm really not meaning to whine, I'm actually quite curious. My last internist (who was great!) used to tell me that when I had a migraine I should slow down and rest until it was over, but I've basically done nothing but rest (and mow my lawn) today.

Ecuador: Day 1-3 Banos

2008-08-03T09:45:00.010-04:00

Even in small town Ecuador, they have Jehovas Witnesses

The chasm into which I bunjee jumped (closeup on the rocks... ;) )

A little house along the route of our biking

I have to appologize for some of my Ecuador posts at this point. Blogger has no tilda.

Anyway, so after collapsing into bed after 40 hours awake (and almost 20 hours of travel), I woke up the next morning.

After realizing that yes, I actually am in Ecuador, I went out for a jog around the park near our hosts house. (Neigborhood pictured below).

On returning, the host family had breakfast ready! And the Spanish lessons begin. Cafe o Te? Hevos reweltos o fritos? An egg, a bun, a banana covered in yogurt, a cup of coffee. With the students. Now, Banyos may not have been my first choice for the only road trip I'd have time for in Ecuador, but the group had been in the country for >1 month, and I kind of figured that I'd hang with them. It made sense.

The plan? Banyos, a little town in the Ecuador highlands about 5 hours by bus from Quito (and about 8000 feet lower in altitude) with tourist stuff and hotsprings (hence the name). Do I want to go? Heck, why wouldn't I?

So, off we go, in a group of taxis to the bus station, and off and away we go on a bus! The ride is, generally pretty. A funny thing about Ecuadorian busses is that their steps are higher off the ground. I didn't really realize this until I fell off the bus. No worries, no real harm done (other than a skinned knee). So, then we drag our stuff through the little town to a hostel called Blanco y Plantas (White and plants, I think). The hostel was indeed white with plants. For $8/day, it was a pretty good deal. The only problem was on the second day of the stay when our shower stopped working (or, perhaps, wouldn't start working). They fixed it (kind of), but when they cleaned up the mess, the mop they used was full of mouse droppings and they spread mouse droppings all around our room. It totally grossed me out, but I managed not to say anything to the other people who, I assume, didn't know that that's what those black things were.

So, after checking in to our hostel, we ate lunch for 3 hours at the Swiss Bistro (this will become a theme. As we learned, it is impossible to eat a meal out in Ecuador in under 3 hours.) Then we went mountain biking. Some of the bikes (like mine) were in tragic disrepair. My chain kept derailing every time I tried to switch gears. There was also an unfortunate straddling incident. Add to that the fact that I haven't biked in 14 years, cut my leg on the chain, etc. etc. made the biking not such a great idea after all for me. Oh, well.

We biked out to a bridge where I bunjee jumped into a gorge. Yeah, it was pretty scary. The scary part is the < 30 seconds that involve the actual jumping (as it turns out, there's some sort of instinct that keeps us from jumping off of high things) until the bunjee cord catches you. After that, it's pretty fun, kind of like flying.

We continued biking, then caught a truck home. There was this kid who hitched a ride with us, who we assumed belonged to the dude driving the truck, but the guy charged us for the kid's fare, so he must have been on his own. I hope his family knows where he is!

So, then we go to eat at this restaurant owned by a guy from Michigan! How odd, but cool. The food was good (sort of a little bit of everything), but the desert wasn't good. I think that Ecuador doesn't understand desert the way we do.

The next day? Shopping, hotsprings, graveyard tours, and then home. Long bus ride.

Sometimes You Need to Talk to A Human (or Lost Luggage)

2008-08-02T21:11:00.004-04:00

I just got back from my course in Maine at 3am this morning (it's now 9pm). They lost my luggage (or perhaps, it would be more accurate to say lost track of, since I had 3 connecting flights and got rerouted around them due to some mechanical difficulties).

This is not an anti-airline rant. I'm actually quite pleased with 3 of the 4 airlines that have been involved in my travels. I will never fly US AIR again, but that's another story.

So, my ticket read as follows: Bangor to NY Laguardia (US Air); NY Laguardia (LGA) to Washington Dulles (IAD) (United) and Dulles to Home (United). I usually fly Northwest (who happens to have a direct flight from Maine to home) but booked my tickets too late to get that flight.

Anyway, due to mechanical problems on the LGA to IAD flight, I got rerouted on a direct flight to Home. Yay! Airline error in my favor! Except the flight left 2 hours late (due to air traffic overload... this happens every time I fly through LGA and so, in the future, I will be avoiding that airport like the plauge. No flight ever leaves on time (except possibly the first flight in the morning) from that airport.) The direct flight to home was on American Airlines. So, I was directed to claim my bags and recheck them with American.

So, while I was waiting for my bags, I was informed that the (delayed due to mechanical failure) flight's already taken off, and that my bags will be joining me at home, or if it's convienient, I can pick them up at the airport. So, I'm thinking, ok, whatever..

As it turns out, the flight combo actually beats me home (mostlly due to air traffic problems at LGA), but my bags aren't on it. The problem here is that I leave for a job interview tomorrow night. It would be good if I had clothes to interview in. I suspect they won't be happy if I show up in capri cargos (2 sizes too big) and a stained t-shirt (which are all the clean clothes I've got left!).

AA has a website you can check your bag's status. However, it always says "your luggage has not been found". You get the same response when you call their automated hotline. However, if you manage to make it far enough through the phone tree to talk to an actual agent, they will transfer you to an actual human being in the baggage department. That human being must have supernatural powers, because she can tell you where your luggage is. She was able to figure out that my bags have actually made it to my Home City and will be joining me at my home tomorrow morning!

Overall, I give United and American kudos for actually trying to make me happy. US AIR now charges $2 for a glass of water on its flights, and they hire the rudest weirdest ticket agents and flight attendants, so they're off my list. I try to avoid American, too, because the checked bag fee annoys me. But in this instance, they were helpful.

The moral of this story? Sometimes you need to talk to a human being.

(image credit)

Ecuador: Day 0 (or Sometimes Getting There is Half the Fun!)

2008-07-31T22:47:00.005-04:00

OK, so the title is slightly facetious. Because I put off buying my tickets for so long, my only flight option to Ecuador involved a 4 hour layover in Miami. So, I waited, and waited. On initial impression, there's nothing in the Miami Airport. The key is to leave the security area and go to the ticketing/check in area. There you will find a nice variety of shops and restaurants. All of which are overpriced and mediocre, but can be used as sourced of nutrition and amusement.

I'm not sure what it is about the Miami Airport, but they're all about Toblerone there. Every shop sold a lot of Toblerone (but none sold Tide-sticks). Also, the laptop and DVD (and Civ4) combo can be key to surviving a long layover. I'm not sure how I ever survived long layovers without that kind of entertainment capability.

The flight from Miami to Ecuador was nice. I was put in a bulkhead seat, which isn't my favorite (because of the fact that I can't keep my carryon with me.) One woman sitting on the other side of me was making a big deal about it, and eventually, the poor flight attendant had nothing to say but "Would you like to change your seat?". Somehow this lady refused both to follow the rules of the bulkhead seat and refused to change seats. This scene delayed the flight a bit, but was quite entertaining!

I arrived in Quito at approximately 6:30pm. The Ecuadorians have a long and rich culture, but they do not have a Culture of Efficiency. Somehow, it never occurs to them that people are in a hurry! It took >2 hours to get through immigration and customs (and they didn't search anything). They just took their time. Ah, well. Oh, and at this point, because I was on call the day before the day I left, and then spent all day the next day getting ready, I had been awake for > 36 hours, and things were starting to seem a little surreal).

So, the arranged car had actually been arranged for the wrong day, unfortunately, and when the guy failed to show up, I figured I'd just take a taxi. Seemed easy enough. I'm not going to call the house and ask my host to send someone to pick me up when a taxi should be easy enough.

Remember, I haven't slept, and my Spanish is non-existent at this point! So, I showed a cabbie the address, he seemed to ask someone else where it was, and then he started driving.....

and driving....

and driving....

and asking random people on the street....

So, 2 hours later (11pm, ~40 hours without sleep), we finally happen on to the right house. I'm greeted at the door, and manage to figure out that the cabbie is demanding $25 (that's a lot for what should have been a 15 minute cab ride in Quito). The medical student who met me bartered the cabbie down to $15 (the fare is, apparently usually around $10).

I'm shown to my room (pictured), which is simple, but adequate for my needs. 2 beds, a shelf, a few hangers. What more do I need? And on my way to bed, I agree to go on a road trip (next Ecuador post!).

Well, This is Different

2008-07-25T21:59:00.003-04:00

I have more Ecuador posts in the works, but I'm in Maine at a course on medical genetics right now, and I think I left the appropriate USB drive at home.

Anyway, It's really funny, when you've been sick for a while, how you can forget where your true baseline lies. I am currently feeling better than I've felt in over a year, despite tapering the steroids from the point when I had to refuse hospital admission. I had a little bout of feeling a bit worse in Ecuador, but over the last week, it's like every day I have more energy, and well, more energy, which is the thing I've mainly been missing. I still have tiny bits of joint discomfort here and there, and the odd ghost of belly pain that floats through, but I've even been able to eat as much fresh fruits and veggies (even salad which has been completely indigestible for me for months), and it's great! I'm loving it. Every meal is an adventure in yummy salads! (which, since I'm in Maine, seem to involve lobster frequently).

It's like... I had forgotten I could feel this good (which is pretty close to what I would have previously described as normal, although I still seem to need to get a good night's sleep on a regular basis). Even though I'm in a course with lectures from 8am-9pm, I still don't feel exhausted. The only bad thing? I feel so good, I tend to not want to go to bed at night (I want to stay up, feeling good), but then I'm tired the next day. (Don't worry, I'm not manic from the prednisone, or anything else, if I actually have the self discipline to go to bed, I sleep...I sleep like a log... that deep sleep where you wake up and feel rested.. and no waking up to go to the bathroom or waking up with belly pain either)

Ecuador Pics, Round 1: Just some pictures I like

2008-07-20T20:18:00.001-04:00

Our clinic waiting room.

Just a plant I really liked

The chasm into which I bunjee jumped. :)
(yeah, really!)

Clinic, day 1: Orientation: Know where the
"Crash Cart" is. (Apparently in the suitcase
in the corner).

Back From Ecuador

2008-07-20T20:05:00.002-04:00

My display issues seem somewhat intermittent (ok, some of them are consistent, but others are intermittent), and I'm stuck in an airport for a long layover, and since my monitor is working a little better (although the good people at Dell haven't yet replaced it... that will happen Tues/Wednesday).

Anyway, some initial Ecuador impressions:

1) Quito has noticeably less air than sea-level!

2) The people of Ecuador are extremely pleasant, but efficiency is clearly not on their list of priorities. We kept getting confused because every time we sat down to eat a meal, it would take 3 hours. Even if it was coffee at a chocolate shop!

3) Managing everyday life while living with an Ecuadorian host family that speaks no English is exhausting when you speak no Spanish.

4) The above is actually doable, particularly when you combine medical students fluent in Spanish, a phrase book, and some determined sign language!

5) Real, hot showers are a too-often taken for granted luxury!

6) The lack of diesel fumes is a too-often taken for granted luxury!

7) The developing world is a dangerous place. I have a whole post coming up on what trial lawyers have actually contributed to our country (I know, seems unlikely to me, too until I saw it).

Hm... now I have to work on the best way to post some pics!

Technical Difficulties

2008-07-19T17:22:00.003-04:00

I have a bunch of posts I want to make about Ecuador, but it might have to wait a while. While I've been back about 5 days, I'm having a lot of problems with the display on my computer.

I can not say enough good things about Dell and their customer service, though. I'm headed out to Maine for a course tomorrow for 2 weeks. I was bummed about not having my computer up and running while I was out there, so they're going to make a house call to me in Maine to replace the LCD display on my laptop. I'm now happy I got a Dell. :) (Although I still periodically think about becoming a Mac person, especially with that MacBook Air. It's so light!!!)

Later!

2008-07-05T01:52:00.002-04:00

I'm off to Ecuador. TTYL!

(image credit)

Quitters

2008-07-01T02:29:00.002-04:00

Dear Colleagues:

I understand if 3 extra years of pain in fellowship isn't for you. I really do, particularly in my program, which for reasons I won't get into here sucks more than many. However, we are supposed to be professionals. This means that 12 hours notice to quit your job (no matter how little you actually need the money you would make from working) is not sufficient. Those of us covering your call, your clinics, and your other responsibilities as well as those of us who have now instantly become responsible for finding said coverage, need more notice than that.

Sincerely,
Me.

Grand Rounds is Up!

2008-06-24T14:23:00.003-04:00

Head on over to see Grand Rounds at Shrink Rap. A really nice job, despite (or because of?) the fact that they didn't include my post (submitted on time, no less!). Their clicky iPhone is totally cool.

Work Hours Restrictions

2008-06-22T09:13:00.005-04:00

Every so often, the ponderings of the medical blogosphere (I hate that word!) turns to thoughts of residents/trainees work hours. Most recently, here and here. There usually seems to be a split between the people who are training now, and the people who trained in the "bad old days", with those who are currently in training saying, "Look, 24-30 hours at a time and 80-88 hours should be enough!" and the "old guys" saying, "Suck it up, it doesn't get any better, you need the experience, besides, we did it, so should you, it's good for you".

So, what are the rules these days?

1) Duty hours are defined as all clinical activity related to the training program (both inpatient and outpatient), administrative duties related to patient care, transfer of care, transfer of patient care, and academic requirements such as conferences. Duty hours do not include hours spent reading and studying away from the site in preparation.

2) Duty hours must be limited to 80 hours/week averaged over a four week period, inclusive of in-house call activity.

3) Trainees must be provided with 1 day in 7 free from all clinical and educational opportunities, averaged over a 4 week period. One day is defined as a 24 hour period free from all clinical, administrative, and educational responsibilities.

4) Time for adequate rest should be allowed between shifts. Trainees must be allowed a period of 10 hours free from clinical, administrative, and educational responsibilities between duty periods.

5) Excessive time spent on duty should be avoided. This means that trainees should work no more than 24 hours in a row, with an additional 6 hours for transfer of care activities. No new patient care should be assigned after 24 hours of continuous duty.

There's also a mechanism for programs to apply for an exemption for "sound educational reasons". (note: There's no reason to apply for an exemption for "sound economical reasons")

Now, truthfully, we have good evidence that acute, chronic, and especially acute on chronic sleep deprivation can impair people's performance on a variety of simple and complex tasks. We even have fairly good evidence that sleepy doctors, particularly sleepy residents are more likely to make mistakes. The Sleep Research Society has collected a handful of studies and citations on that very topic. Sadly, I'm at home, so I don't have my super-duper full-text access, but briefly, their review found evidence that sleepy trainees make 5 times as many diagnostic errors, suffer a 1.5 to 2 standard-deviation deterioration in skills level, and make fatigue related errors that result in patients' deaths. Their findngs are appropriately cited.

What has been more difficult to show has been that reducing work hours actually improves patient outcomes. The standard excuse has been that transfer of care of patients actually increases errors. While I don't doubt that that's true, or, at least, I don't doubt that it has the potential to do so, the fact is that eventually everybody must go home. Also, "signout", the transfer of information at the end of a shift, is a skill that can be taught. As is taking care of patients you're not entirely familiar with. Face it, when I was an intern in charge of 20 postpartum patients at night, it's not like I knew them all. I had to look at their charts to manage their complications. And let's face it, if you're a resident managing a team of 5-10 patients, you may know your patients well. But once you have more than 10 patients you're responsible for, your likelihood of really knowing the patient well is really small. Not only that, but the studies also haven't shown that resident work hour limitations actually endanger patients. One of the theories of Dr. Czeisler (a guy from Harvard who's done a lot of the studies on sleep and physician performance) is that the work-hours limitations are not enough. That you really have to get under 16-18 hours of continuous duty in order to reduce errors, so that we're not seeing the beneficial effects of well rested residents yet. Although people equate the lack of proof of improved patient outcomes with a proof of more errors as a result of turnover, there isn't evidence that resident work-hours restrictions has actually caused patient care to deteriorate, either.

I had a friend who was a general surgery resident. When she ran the Neurosurgical unit, she was in charge of 50+ patients on any one day. Did she know those patients? Not even a little bit. All she could do was to do her best to avoid drowning. She got to work every morning at 330 am, and on a good day, she left the hospital at 830pm.

Was she learning? Not really. She was dictating discharge/transfer summaries, and writing prescriptions all day long. She never entered the operating room, and any patient who got sick was seen by her 2nd year resident and transferred to the ICU. These were all patients waiting for various transfers to long-term care facilities. This was a terrible abuse of her time. And she's now an anesthesiologist because of that. (Those of you who are concerned about the recruitment and retention of general surgeons should think about this).

The Libby Zion case is often cited as a catalyst for work hours restrictions, the Libby Zion case was more a mistake of judgement rather than an exhausted resident. The truth is, hospitals like residents to work these extended hours doing scut work so that they don't have to hire nurse practitioners/midleves who actually need to be paid (Residents are paid by Medicare funds, and the hospital gets ~US$100,000 per resident, of which the resident gets ~$40,000; the rest goes to fund educational programs, malpractice insurance, and other costs of running a training program.) Hospitals may not be getting rich on resident labor, but, especially in large expensive cities, residents represent a huge cost savings when compared to what it would cost to hire phlebotomists, transporters (it still is not uncommon for residents to transport their patients for surgery or tests at the hospital I work at, and I view this as a HUGE abuse of their time), and nurse practitioners.

Another reason for reducing resident work hours from the traditional 100 hours+/week is that of safety of the actual residents. The Sleep Research Society in their summary includes the fact that tired residents are much more likely to have needlestick injuries and car accidents. OSHA makes rules to protect the health of workers all the time. Why isn't it valid to protect the health of residents? I certainly have given a lot of my life to medicine. I'm not willing to risk death at the wheel for the sake of not turning over patient care to another fellow.

Are there arguments for extended shifts? There is at least one reasonable educational argument. If you're not around for a long period of time, I think that it is true that you simply don't get the same appreciation for labor, for the course of disease (like a bowel obstruction) that you do if you follow the same patient for 24 hours. So, the 24 hour limit may end up being a reasonable compromise, long enough of a time to see disease/physiology evolve but not so long that the resident becomes a menace to himself and to others.

Having said all of this, I was a med student in pre-work hours restriction days, a resident in a very well-intentioned but not completely compliant program and now I'm a fellow in a less well-intentioned but more compliant program (for the residents); I'm at the point where I make my own decisions about how to structure my schedule to comply (or not) with the rules. And because of some health stuff, I mostly try to work less than 100 hours a week, no more than 24 hours at a time and take at least 1 day off each week. I don't have much to complain about. We were not compliant with the rules when I was a resident, but my program was cognizant of the need for rest, and when we were exhausted, we often got sent home (particularly if we were exhausted because we stayed late for interesting cases/continuity patients/etc.)

I will also say, that although some in the old-guard will rail against the new restrictions, they're in place because of examples like my friend above, where the old system was so abusive that it could no longer stand. In a way, the work hours restrictions that are in place now that people who trained in other eras are so against, are the result of the (formerly much more) abusive system that let work-hours be so abused in the first place. If attendings would have stuck up for their residents and said, "You know, my intern's too busy learning to be running my patients to x-ray, you need to hire some transporters" or said, "You know, my intern might be able to scrub on a case if she weren't writing discharge prescriptions for 50 patients, you need to hire a midlevel", things may not have changed this drastically. Things are how they are, and they are how they are for many reasons; and you know, I think that although there are still problems, it's a change for the better.

And for the record, I'll take the resident who's not so tired he's envying the patients under general anesthesia, and the resident who's not so tired he resents it when my nurse calls for an anti-nausea or pain med order over the resident who's been in the hospital with me every day and night for a week, if it ever comes to that. I also do not expect that resident to risk injury/death due to fatigue in order to "take care of me". Besides, what kind of a society are we when we expect a class of essentially indentured servants (admittedly, indentured servants who can expect a healthy reward at the end of their servitude) to take such risks on our behalfs?

(image credit)

Compliance and the Social Contract

2008-06-14T18:03:00.006-04:00

I've been having a post about compliance bubbling around my head for a while. And my recent pseudo-(or actual) non-compliance is probably a good reason to post about it.

Anyway, patient compliance. There's sort of an unwritten contract between the sick and the well. The well will try to fill in for the sick. The sick will do whatever they need to do to get well. That's why it is annoying to see a co-worker in a movie theater when they've called in sick and pushed their responsibilities off on to you.

I feel like there's a similar social contract in medicine. The patients pay (or not, really) docs for advice about how to protect their health or how to get better. The doctors, in return, come up with a plan with/for the patient. In the best of all worlds, the doctors and patients work together to come up with a plan that will work for the patient. The doctor helps to come up with the best plan the patient is able to comply with. This means that if the patient doesn't want to be admitted to the hospital, or can't be admitted because of childcare issues, that patient should tell her doctor.

Similarly, if a patient doesn't plan on (or isn't capable of) modifying her diet for her gestational diabetes, or taking her blood pressure medicine, she should tell me. I understand that people can only do so much. I understand that poverty and chaos are huge barriers to compliance for our patients. I'm not terribly judgemental, and if someone says to me, "I can't do x, y, or z", I will explain to them why that is the best thing to do, and I will try to help find ways for the patient to follow through on the best plan. Sometimes we can get assistance for people with their utilities if they don't have electricity for their refrigerator for the insulin, for example.

Sometimes, it's a matter of troubleshooting what's going on For example, I had a patient who couldn't see the marks on her insulin syringe to give herself insulin, and couldn't afford the glasses she's needed for years. She could see the 10 Unit demarcations, so I rounded her insulin doses to the nearest multiples of 10.

And sometimes, there's nothing I can do. Our medical system can't really arrange good childcare for people with no social support when they need to be in the hospital. The closest they can come is a medical foster home, and many parents are (understandably) unwilling to put their kids in foster care for the sake of being on bed rest in the hospital.

Having said this, as their doctor, I need to know what my patients are willing and able to do. The only way I can know this is if patients will take responsibility for their health and tell me what's going on; what they can do, what they can't do, what they won't do. There's no sense in coming to see the doctor (as many of my patients do) if you're not willing or able to do what I suggest and not willing to tell me that so that we can come up with a "second best" plan. I actually regard that as a waste of my valuable time. And, to be honest, I'm surprised that so many of my patients don't view it as a waste of their time, actually!

For example, even though, for many patients, insulin is the best treatment for diabetes in pregnancy, if you can't (or won't) take insulin, I'm willing to try to work with diet and with oral medications to get the best control possible. If you can't be admitted to the hospital for certain complications of pregnancy, I can arrange outpatient blood pressure monitoring and fetal testing, which, while it may not be the preferred form of management, is often better than nothing.

(image credit)

Excuses, Excuses....

2008-06-12T18:18:00.004-04:00

Interesting conversation with my gastroenterologist. I saw him because I was having a flare of whatever IBD it is I have (he now thinks it's Crohn's Disease, and at this point I don't care what I have, as long as it can be treated; the repeat scope and upper gi can wait for now, because the treatment of an acute flare is usually the same). Well, long story short, my hemoglobin got down to 9 (sort of mild-moderate anemia), I dropped 10 lbs in 5 days (much of which, I'm sure, is water), and I was having such a hard time eating and drinking that I ended up in caffeine withdrawal (which always makes me particularly pathetic). So my gi doc said to me, "You need to be admitted to the hospital for 3-4 days for high dose IV steroids", at which point I said, "No, thanks, I really don't have time to be in the hospital". So we had this talk about how I'm not indispensable... and I still refused.

It was very interesting to hear him say to his nurse, "I told her she really needs to be in the hospital and she said 'no'".

It's also clear I haven't told him my history of having left an ambulance with a skull fracture AMA, of 'declining' admission for a bilateral pneumonia in medical school.

I agree with him, that the excuse of, "I don't have time to be sick" is really just that, an excuse. It's also true that when I'm not feeling great, the LAST place I want to be is in the hospital. Particularly my hospital. Particularly for 3-4 days of IV steroids because I get a little restless (read: am already a little restless) on high dose oral steroids, I'm sure I'll get bored and restless in the hospital on IV steroids. Maybe that's also an excuse.

Also, I generally perk up pretty quickly on oral steroids. I'm already feeling better, approximately 6+ hours after the first 60mg dose of prednisone and have been able to get some diet coke down to fight the caffeine withdrawal headache and actually eat something. Although, I am having a lot of hip pain (damn you extra-intestinal manifestations!). Perhaps that's just another excuse. Although, perhaps, he didn't realize how resilient (read: stubborn) I am, particularly when given a whopping dose of prednisone. It has annoying side effects, but I get better pretty quick. No need for 3-4 days of IV steroids! I'm also a lot better, in general, at eating and drinking a bit, when I'm resting, so maybe just taking the day off from work will help. Or maybe he did know this, because it was the threat of being put in the hospital that made me take the day off to rest and drink in the first place. Hm..... suspicious.....

(image credit, no it's not me)

Teaching to the Tests?

2008-06-08T19:41:00.003-04:00

I go back to work tomorrow (help, I'm not ready!). Actually, seriously, I'm not ready. One of my tasks tomorrow is to give a 3 hour board review session to the chief residents who are taking their ob/gyn written boards in about 3 weeks. I'm not exactly sure what I can do to be helpful to them.

I was thinking, though, that maybe some general assessment of where they are in their knowledge, coupled with some test taking skills is a good place to start (I have 2 more 3 hour sessions with them).

Not to toot my own horn, but I've always been a pretty good test-taker. Not that I don't study, but I consistently get really good scores on tests (my USMLE scores were all in the 235-255 range (~95th-99th% for you non-doctor type people)) even when I haven't earned that high of a score, by virtue of studying alone.

And not that people shouldn't know the material, but really, test taking is a good skill for a doctor to have. Helps with all of those tests we have to take. ;) So, one of the things I thought we'd talk about first is how to approach questions when you're not sure of the answer (i.e. read each of the options carefully and eliminate those you know aren't the answer. Try to figure out what exactly it is the test is trying to assess). Read each question carefully. Mark those questions you aren't sure about and quickly go through the test to answer all of the questions that you know the answer for (although do it accurately, too). Then go back to the questions which require thought (and math). But you never want to miss the opportunity to answer a question correctly if you know the answer.

And sure, none of these are fool proof techniques. For people who have marginal test taking skills or a history of marginal test scores, though, they can make a real difference.

And while I have no ethical qualms, exactly, about teaching test taking and teaching to the test a bit, I do have to wonder about a system that puts so much power in a single test (the written board exam), which is a poor measure of what you know about obstetrics and gynecology. After all, some great doctors are terrible test-takers, and some terrible doctors get great scores on all of their tests while consistently failing to have common sense, compassion, or empathy.

(image credit)

Somebody Call that Cat A Toe Truck!

2008-06-08T19:31:00.004-04:00

So... there's this running joke in my family about broken toes (which I've had several) and toe trucks. Somehow this joke annoyed me until I was about 20, and then it made me laugh and laugh.

So, I have this cat, see (pictured).... He's really quite large. Even if he weren't a fat cat (which he is, but he's not bizarrely fat.. his belly doesn't touch the ground or anything), he'd be huge. As it is, he weighs 30lbs, which I think makes him as large as some medium size dogs (when I take him outside, he wears a medium size dog harness).

So, I went off to a picnic thing today and I come back, and he's sleeping. Not all that unusual, he does that a lot. He came out to get his food when I fed the kitties today. Now he's sleeping /sulking in my office. Most of the afternoon. I tried to get him to get up to make sure he's ok, and he kind of glared at me. My other cat laughed at me as I try to push this 30lb puma across my office to make sure he can walk. Hm.... the cat's limping a little.....

I attempted to examine the cat, and all I came up with was a worried look (from the cat in question) while feeling around his toes. We had some dramatic thunderstorms, and sometimes he gets startled by the thunder. In fact, now that I think about it, I can remember hearing him crash to the floor.

I bet he landed a little funny and hurt his toe. His knees/hips all seem ok, and he doesn't seem in that much pain. And he will now walk when given a good enough incentive (his favorite food or catnip). But all I could think is, "Sylvester needs a toe truck!" ;)

More About my Mom

2008-06-05T14:38:00.003-04:00

So, people reading my last post about my mother may think that I don't like or love her. Nothing could be further from the truth. It's just challenging, having lived my own life, to try to communicate with her, sometimes. She doesn't really live in reality.

To be honest, I don't think it's all her fault. About 20 years ago, she was in treatment for her alcoholism, and being treated for her depression, and mostly things were pretty good. Although, she would occasionally inappropriately lash out at us kids (like, when we didn't want to go to AA meetings with her, would accuse us of not wanting her to be sober... which isn't a fair accusation to make to a teenager in that situation, it would take more maturity than I or my sibs posessed to want to go to an AA meeting). It certainly was a big improvement. But when we moved overseas for a while, she stopped going to AA, she stopped having her depression treated, and I believe that my mom's depression and her alcoholism are inextricably linked. She had a "relapse" that has now lasted more than 15 years and has, on numerous occasions posed serious threats to her health. All of my brothers and sisters and I have tried to talk to her about it at various times, as have her doctors, etc. None has had any impact. All have earned some degree of hostility from her. At this point, she's going to have to come to the conclusion that it's time to stop (or not) on her own.

I also feel like her depression and her drinking (again, hard to separate what is what) really change the way she views the world. Everything is seen as a possible slight or in the most negative way. For example, when she and my dad were separated, she thought my little sister was "taking her place" with my father. Now, my dad was far from perfect, but he wasn't that kind of guy. And even if he was, it wouldn't be my sister's fault.

What on earth does this have to do with my vacation? Well, my mom said to me as I was leaving, "When you lie to me, it makes me feel like you don't like me very much.". I didn't lie to her, but I did neglect to tell her I was visiting with my older brother over Memorial Day weekend, until I saw her on the Tuesday afterwards, at which point, I said, "I realized I hadn't told you I changed my plans, I spent Memorial day with OlderBrother.") I changed my plans after I told her what they were. I explained this to her, but she doesn't believe me. She really prefers to think that I'm plotting against her behind her back with my siblings. I apologized for not telling her sooner. And while I just didn't think about it, it is also true that sometimes it's easier for me to not talk too her about things, and that sometimes I get frustrated and decide that she can be the one to call me for a change. I think all of these factors sort of played a role in my not making that extra call to let her know. Although, I am 33 years old, if I want to spend Memorial Day with my older brother, it is my choice to make. I do think that her depression and her alcoholism have sort of changed her brain or her mind in a way that makes her see things in a very negative way, and be unable to reevaluate this, and that part of this isn't her fault, entirely.

I also wonder if what she's trying to say is, "I feel a little left out of your life.". Usually, I'm a person who believes that people say what they are saying, and I feel a little bit bad about assigning this motivation (unspoken by my mom, of course) to her. But really, she is a little left out of my life. I worry about her, and because of that (and the fact that she sometimes doesn't seem able to understand how I feel), I don't tell her about stuff that will stress her out (like about the ways in which my current job sucks, the fact that I'm sometimes a bit lonely here, the fact that my UC has been annoying and difficult to control). I haven't told her that I'm a lesbian.

Maybe in a way, this conflict between my mom and myself is a consequence of my actions. I think she's mistaken for feeling like I lied to her, but maybe if I make more of an effort to share the little things with her, she'll be less likely to assume that I'm trying to be deceptive and secretive?

I want to go home.

2008-05-28T12:05:00.003-04:00

"I just wish you'd come here and have everybody else come see you." (While getting angry with me for visiting my older brother)

"Your brother loves you, you know, and his dad and older brother rejected him" (Not exactly true... my father didn't ignore my younger brother any more than he did the rest of us, and my older brother just didn't really grow up knowing my little brother (hi bro! I love you), and it's hard to bridge a 14 year age difference sometimes).

"Well, you know, some doctors are drunks" (when said by an alcoholic, who's actively drinking, about the medical malpractice crisis)

All of that, plus the endless parade of FoxNews (when I told my mom I didn't like Bill O'Reilly, she said, "Well, have you ever tried it?"), and crime shows (When I asked to watch something else at dinner because the crime shows about the rapes and the murders and the endless news about all of the terrible things that happen really kind of gets to me, the tv was turned up. And hey, isn't my visit a special enough occasion that we can eat dinner and talk without the tv on? ).
And part of this is my fault. I keep hoping things with my mom will be different, and they never are. I should know better. And I will admit it, part of my agenda for this vacation is rest and relaxation. And part of the issue with the tv, I think, is that they're bored (my mom and aunt, her sister), and lonely, and I should be more understanding. And, perhaps, I'm getting less flexible as I grow older.

But still, the parade of comments when I tell them I might go jogging in the morning.. about not wanting me to leave because of rapists and thieves, etc. when they live in the safest gated community in a very safe town in a safe part of a safe country. The fact that everything I do is a potential slight to my mom (and it's not meant as a potential slight. The things I do are just the things I do, from visiting with friends while I'm here to jogging in the morning, etc). The fact that she treats me like a child ("I can show you how to cut up a canteloupe."), and I'm in my early-mid thirties. The fact that she acts disappointed when I tell her I don't want to go to Seattle for her to take me shopping... let's face it, my mom has a number of chronic medical problems, and she never gets out of bed before 1pm. It takes her 3 hours to get through the grocery store. And I brought plenty of clothes with me. It's very sweet of her to want to take me to the mall (80 miles away), but not very practical. It takes her 3-4 hours to get ready to leave the house. We'd be lucky to get to the mall before it closed. And I can't take my mom out to buy me stuff.... that's just not right. I'm not a kid any more.

And I don't want to stay up until 5am and sleep until 4pm. I want to enjoy the day.

And then there's the times that she talks about how one day she'll need money from me, or she may need me to stay with her and take care of her. Well, that's just not happening. I'm not going to provide for her or live with her or be her caretaker, although if she really were to stop drinking, I might consider it, but only if she were to start treating me like an adult. I know it would totally hurt her feelings for me to say this to her....

At least I'm headed off for the weekend. I only have 4 nights left. (including a 2 day break) Then it's over. I don't know if I'll make this trip again any time soon.

The next time I visit my mom, I'm not staying with her. I'll stay with my little brother or maybe in a hotel.

Having said all of this, I do really love my mom. I think she loves me too. It's just she's been getting away with acting how she acts for so long, and I've spent a long time not having to put up with it.... And I should be more flexible and patient, I admit that.

Vacation log blog

2008-05-22T01:34:00.005-04:00

I've been on vacation now since 7:15am Monday morning. I have a total of 3 weeks of vacation time left to take (because I haven't taken any vacation (ok, I've taken 3 of 21 days of vacation, so now I'm taking 15, and I think I'll probably loose 3 days), and all of my vacation goes *poof* and resets in July, it doesn't accumulate between academic years). I've completed the list of tangible things I was supposed to do while on the vacation (although I probably need to mow the lawn one more time before I go back to work).

My goals:

Hang out with the family

Reconnect with some old friends from residency

Sleep... sleep and more sleep. I've added my 4th alarm clock to the rotation (thinking that the reason I can't get up in the am is that I'm too used to my alarm clock), and someone suggested that perhaps the reason I can't get up is because I'm possibly just tired... hm... that may have a little truth to it

Figure out what I want to do with the rest of my life.... do I sell out and go private practice and have a nice life? Do I slave away in academics despite the fact that I don't really like research all that much (it's not that it's not interesting, it's just that what motivates me to get up in the morning is taking care of patients)

Figure out how to tell my attendings that I think I'm going to get a private practice job when I finish.
On Monday:

Gone to a lecture at work (um... yeah... I agree, that was an odd choice)

Got my travel shots for Ecuador. Yellow Fever, typhoid, hepatitis A, Diptheria/Tetanus

Ate a pizza bagel

Napped for 4 hours

Had 2 hours of Tae Kwon Do

Came home and slept poorly (lingering postnasal drip from the cold. I would fall to sleep and wake up drowning in my own phlegm, but the combo of sudafed and benedryl eventually helped)

On Tuesday

Slept until noon

Ran errands to prepare for trip to the Pacific Northwest

Cleaned my house

Met with kitty sitter

Ate pizza bagel (I do love pizza bagels... an odd addiction)

Went to 1 hour of tae kwon do

Did laundry for trip

Went to bed at midnight (the laundry took too long, the loads were a little too big and the clothes took longer than I was expecting them to dry).

On Wednesday:

Got up at 6:30 am to go to work to meet with residents (what can I say, I'm not terribly good at vacationing)

Picked up laundry

Mowed lawn

Payed bills

Fixed old financial aid hold at medical school (a loan I've actually paid off, but they hadn't removed the hold)

Fed cats

Cleaned catbox

Flew 2000 miles across the country to the land of salmon and cedar and $4 coffee. ;)

tomorrow? Sleeping, reading.... maybe some time in the pool. :) Maybe the new Narnia movie. Friends from residency. What more do you need?

(image credit)

Pushmower

2008-05-17T12:32:00.003-04:00

I mow my lawn with a push mower. Kind of similar to the one pictured here.

I don't believe it's all that much more difficult than a gas powered lawn mower, and definitely has a smaller carbon footprint. It's also good exercise. It also causes people to talk to me, and since I tend too be a little bit less social than might be good for me (although it's a step up from my previous social rating of painfully shy), that's also a good thing.

I had a conversation with my next door neighbor, with his working-man hands, and his Afghan poppy plants, and the almond tree he's trying to grow. He said, "you're too heroic", and told me a story about how everybody in the neighborhood had tried the push mower and eventually got tired of it, and about how they all switched to power mowers.

The little farmers market/street market that's down the street was playing some fun music, and the birds are out. And, when you mow with a push mower, you can hear them all, too!

A push mower might not be for you if:

You refer to your lawn as "the back 40"

You are a perfectionist with respect to your lawn (it doesn't do as good a job as a powered mower, and the "self mulching" "feature" means that the grass grows in a little less dense, unless you rake the lawn after you mow it)

You have a lot of sticks in your lawn! (even if you think you can get over a stick without it stopping the mower, you're probably wrong!).

You have a lot of hills in your lawn

Hm.. I guess that's it. I have a medium sized lawn, and mowed it in about an hour. My heart rate was in the aerobic range for almost that whole time. Good exercise, minimal pollution (unless you count grass clippings), sun, and neighbors.

Overall, I give the push mower experience a "B+"

(image credit)

Drowning in Phlegm

2008-05-17T11:19:00.003-04:00

Why is it that nuisance ailments such as a cold are so annoying? I mean, if the cold virus was planning its attack strategy, it's done a good job. I'm literally a fountain of infectious mucous, mostly originating in my sinuses and then running down my throat and nose.

Yet, I'm not sick enough to stay out of work (although it's Saturday, and I think I'm going to go in to work if mowing the lawn doesn't kill me, but nobody else will be there, and I didn't get a whole lot done this week), so I can go and (theoretically... in the days before hand washing and anti-viral tissues) infect more people.

It is a perfect evolutionary strategy for a virus. After all, if it made people sick enough to stay home, that would limit it's infectiousness to household contacts. As it is, people can wander about as they please and infect unsuspecting bystanders (like me!).

The rhinovirus is a magnificent feat of evolution.

However, I still don't like that choking sensation as the phlegm drips down the back of my throat. Sudafed... Claritin.... Benedryl (at night), they all help, but there's still no cure for the common cold (except maybe rest and fluids, but I'm not into rest!)

(image credit)

Could I Be Any Less Productive?

2008-05-14T16:02:00.003-04:00

Yesterday was a gorgeous day in America's 3rd world country. The sun was shining, it was not cold outside, the birds were singing, so after 2 attendings told me that I should take some time to enjoy it, I left. I wasn't getting much done anyway.

Then, today, I've been trying to do some data analysis. One is from some genetic stuff, and it involves more than 2 million data points, and I did some of it by hand before and now the analysis is automated, and I'm trying to make sure I got different results because I made a mistake with the manual analysis (not a big stretch there).

But mostly, I've spent the day reading blogs and pondering my coming night on call tonight. I've been chatting with the other people in the lab. I walked over to the hospital cookout. I've been thinking about how I only have 50 call nights left as a fellow (assuming I do the analysis and finish my thesis!). And trying to decide what I really want to do when I grow up. But mostly... wasting time.

There are some days that I just can't do data analysis on 2 million data points.....

Somehow I can always get my act together to see and take care of patients.

What do people do on days like this in the real world where their productivity matters more than mine does?

(image credit)

What I'm Going to Do on My Summer Vacations

2008-05-11T14:51:00.004-04:00

That's right. Summer vacations. Our "vacation year" (is that a real term?) runs from July through June (like the academic year). I haven't taken real vacation in over a year, and I don't believe in letting vacation time go unused. So, I'm taking 3 weeks off, starting in 8 days. During that time, I will clean my house and go to visit my family. I'm hoping it will be relaxing, although there's always that family stuff. The fact that my mom always resents my visiting other people other than her (although, really, that shouldn't be my problem. I've taken to telling her my plans and expecting her to deal with it, which isn't a perfect solution, but.... really.... she's a grown-up, she has to learn to act like it).

Then, in July, I'm going to Ecuador to provide medical care for a week (as it turns out, there's not a lot of docs in Ecuador). The hilarious part of this is that I'm helping to staff a general medical clinic. I have done no general medicine in 6+ years, and I speak no Spanish. I'm told that this won't be a problem. If anybody has any good medical Spanish references, please feel free to let me know! I want to go see the Galapagos, but I'm not sure if that will work out with my time and money restrictions. Having said that, I'm about 14 months away from becoming an attending, and so, I may just do the Galapagos as a separate trip then.

Then, later in July, I'm going to Bar Harbor, Maine for 2 weeks for a course on clinical genetics. I think of this as "summer camp for grown-up science geeks". Seriously, it should be fun. And since it involves the Hyatt Regency, I don't think we'll really be roughing it all that much.

Then, in August, I have a couple of job interviews I'm working on lining up (more later, one of the opportunities sounds perfect, but I have to decide if I still like the geography). I'm also giving an oral presentation at the International Society for Ultrasound in Obstetrics and Gynecology.

All in all, a busy summer. Too bad I can't plan on hibernating next winter!

(image credit)

Self Indulgance and Exercise

2008-05-04T10:37:00.003-04:00

I have many posts I've been meaning to do.... home births, non-compliance, the rising c-section rate, teaching residents, the fact that nobody ever listens to me (heh!), but instead of blogging about something important, today I'm blogging about me...

So, I've been on prednisone for the colitis for most of the past year, with doses averaging at about 20mg, but on 10 mg for the past couple of months (ever since I saw New GI Doc). I'm not symptom-free on 10mg, but my symptoms are manageable and tolerable on that dose. It's not a very high dose, but there's still a difference (for me) in side effects in being on 10mg vs 0 mg of prednisone. Most of the side effects have to do with appetite; and since my weight's always been a bit of a struggle, well, being on prednisone at any dose isn't terribly helpful with that. Also diabetes, vascular disease, and osteoporosis (my mom had an osteoporotic hip fracture a couple of years ago and has some vertebral compression fractures... pretty severe osteoporosis) are concerns on prednisone. Exercise actually reduces the risk of all of those things, helps with weight control (although whether or not it helps with actual weight loss is debatable, I think it does), and it makes me feel good.

So, I started jogging, which I liked more than I thought I would, and still do, especially since the sun is coming up earlier in the morning now, and soon it will be dawn when I'm out jogging at 6am. I like jogging at dawn. But the problem with jogging is that it's lonely.

And I get lonely here sometimes. I mean, I work with plenty of nice people, and I have plenty of friendly acquaintances, but no real true friends here (although I do have friends from other places I talk to on the phone at times). It's part of the price of living a nomadic existence during medical training, sometimes.

And I needed a hobby. I liked pottery, but didn't have much in common with the other people who took pottery. So, then I tried tae kwon do, and it's been a lot of fun. 2 hours every night I can make it of kicking, punching, throwing, and self defense. And the people who go tend to be people who I have something in common with, in general. Even though I haven't found my BFF there, we chat and laugh, and it's a good time. In fact, I got my yellow belt (which means I'm not a newbie any more) on Friday, and I will be sticking with the tae kwon do for a while. I think I want to get a black belt.

But I also still like jogging, and that's a good 45 minutes of time in the morning. You add that to the tae kwon do in the evening, and maybe throw in some strength training (so I can keep improving my upper body and core strength, which could use some help), and that's like 3 hours of exercise a day.

I know that my program directors (we have 2 for the fellowship) would think that spending 3 hours on exercise, plus the time I need for ADLs (15-30 min a day), plus the 8 hours (and when I'm exercising this much I really need 8 hours) of sleep would think that it's all self indulgent, because when you do the math, I can only spend 10 hours a day on work and do all of this exercise.

24-8=16-3(exercise)=13-1(driving)=12-1 (eating)=11 -1 (ADLs, blogging, tv, etc)=10 (work).

If they knew, their argument would be (and I've heard it before, but not directed at me) that I should spend all available time while I'm a fellow on my fellowship, and that this sacrifice will pay off later. Or that I should sacrifice sleep for my exercise (although like I said, all this exercise makes me need more sleep... and makes me sleep like a rock) or for work.

I've come to the point where my tolerance for this level of sacrifice just isn't there any more. So, I continue my self-indulgent level of exercise, mostly in secret, so that the powers that be at work don't find out.

Having said this, it used to be that doctors (both in training and after training) gave up everything: exercise, family, sleep, activities of daily living, absolutely everything, in order to be doctors. And all of my current attendings trained during that era, so to them, my 3 hours of exercise, 8 hours of sleep, and an hour of adl's really probably does seem self-indulgent, and it isn't their fault, entirely, that they view medicine and life like that.

And maybe this is a temporary phase in my life. Perhaps, I'll return to working harder on work soon. Figuring out where a good work-life balance actually is is really quite difficult, and I expect that that balance will shift for me quite a bit as the years go on.

(image credit)

Six Word Meme

2008-05-02T22:24:00.003-04:00

A long time ago, I was tagged by TBTAM for the six word memior meme. The instructions? Write a 6 word memior and tag 6 others.

Catch a baby, watch the floor.

I'll tag all three shrinks at shrink rap, someonetc, RLBates, and Mark's Tails.

Still Alive

2008-04-28T17:40:00.003-04:00

Hey everybody, thanks for the inquiries. I'm still alive, just working a lot. I'm on clinical service right now, and working at least 12 hours/day, plus prepaying my call so I can take all of my vacation (I have 3 weeks left) in May/June.

So, if you haven't given up on me, thanks for not giving up on me. If you have, well, then, that's your fault.

More soon. I understand I get my life back at the end of the month. ;)

Bruce is Still the Boss

2008-03-30T09:57:00.004-04:00

I am finally back up to ~35 minutes of jogging (approx 3 miles for me. I'm slow, but stubborn). Anyway, as I was jogging this morning, I was listening to the new Bruce Springsteen album (Magic) on my ipod, and I have one thing to say: Bruce, you still rock!

I especially like "I'll work for your love" and "Radio Nowhere"... in fact almost popped into spontaneous dancing while jogging.

"I'll work for your love" is a fantastic little rocking love song. "What others may want for free, I'll work for your love. The dust of civilization and love's sweet remains... slip off of your fingers and come dripping down like rain." :)

And "Radio Nowhere" just plain rocks! "I want a thousand guitars, I want to pound them drums, I want a million different voices speaking in tounges.... This is Radio Nowhere, is there anybody alive out there?" Great song about connections or the lack thereof.

Other songs on the album, including "Last to Die" (about how can we ask our soldiers to be the last to die for a war [in Iraq] that is clearly a mistake).

(image credit)

It's not your fault, except when it is.

2008-03-21T18:25:00.003-04:00

So, departing from the world of my gut for a (hopefully long) while....(Although if anybody has any suggestions on getting rid of erythema nodosum, let me know. They're not a big deal, but they're kind of annoying).

I was on call last night. And like most nights, we had a woman on labor and delivery who was loosing or who had lost her baby. And it seems to me that it almost doesn't matter if the loss is at 22 weeks (prior to viability) or 40 weeks, if it occurs after quickening (the time when the mom first feels fetal movements), the grief is always severe.

When women (and their families) are caught up in this terrible grief for this terrible loss, their first assumption is that the baby's death is somehow their fault. In ~90% of circumstances, this is not true. And those women, I always tell, every time I see them, "Remember that this is not your fault. This is a terrible thing, but you did not deserve this." I'm not sure that they believe me, but I think that telling them that is part of doing no harm, as it were. The loss of a child is such a terrible thing for most women, and sometimes heralds the onset of another disease (some women, for example, are diagnosed with lupus only after having a lupus related stillbirth), families have so much potential for self doubt and guilt, that if I can limit the amount that they torture themselves with guilt, then maybe even though I can't save their baby, I've still helped them.

But what about that 10%? The 10% of stillbirths that are preventable. The 10% of stillbirths that are due to uncontrolled diabetics, or patients who did not comply with our recommendation for fetal monitoring once or twice a week? What do I tell those patients?

I think that the diabetics make the best example. Diabetes is the reason Maternal-Fetal medicine came into existence. Way back in the dark ages (pre-insulin), diabetes used to be a death sentence for pregnant women and their fetuses. Then, insulin arrived, and not long after insulin (just a couple of decades, really) fetal monitoring became routinely available. These inventions changed the whole game for pregnant diabetics. With diabetics surviving their pregnancies, we (ok, not me, I wasn't even born then, this is ancient history) noticed that a large portion of their babies died as they got closer to term. We tightened their glucose control, and then we were able to monitor their babies for problems. (The mechanism of diabetic stillbirth is still somewhat subject to debate, but the prevention of it is not) Now, we work towards tight glucose control through pregnancy and twice weekly fetal monitoring after ~32 weeks in all pregnant diabetics. This has resulted in a fairly dramatic decrease in diabetic stillbirths, to the point where diabetic stillbirths, once expected, are now rare. This improvement in pregnancy outcomes for diabetics is the first real success of Maternal-Fetal Medicine.

Most diabetic stillbirths, in fact, occur in patients who are non-compliant with their blood sugars, insulin, and their fetal monitoring regimens. During pregnancy, I give them my "You need to do these things, otherwise your baby could be seriously damaged or die" talk (dead baby talk for short). And despite the dead baby talk, a subset of our patients will not follow our recommendations. Now, I know most of our patients are very poor, but they all get free care through us. We have a baby van that tracks them down and brings them to their appointments. We make sure that they have the appropriate emergency Medicaid so that they can get their insulin. And in fact, few of them have jobs, which makes it easier for them to make their appointments. And we never ask them not to bring their 12 screaming children into the waiting room. We just want them to come however they can, with or without screaming children. Without hospitalizing them for their entire pregnancy and administering their insulin to them (and sometimes we do that, but it's not practical to keep people hospitalized for 9 months of pregnancy because they're non-compliant), we could not do more to make them able to comply. And, rather than telling us they're not taking their insulin, etc. they bring in fake blood sugars. I think it is a case of denial...they don't believe it will happen to them. That combined with the fact that many diabetics don't feel bad until they're really really sick.

So, these noncompliant patients get dead baby talk after dead baby talk. And they have a much higher rate of fetal death than the compliant patients (whose rate of stillbirth is still higher than the general population, but not by a lot). So, when these women come in with their stillbirths, although part of me wants to say (just to be compassionate), "This is not your fault", the other part of me keeps me from saying those words, because they're not true.

I don't know that it really helps the patient to hear "This is not your fault" when it is kind of is their fault. In some ways, these women are suffering a consequence of their lack of personal responsibility (I know it sounds pretty harsh to put it like that). If these women choose to get pregnant again, they deserve to know that they increased their risk of having a stillborn child by their bad behavior. Because if they behave the same with the next pregnancy, they may very well get the same result. And the only thing that's worse for a mom than a single stillborn baby is recurrent stillbirths.

In fact, when women come in for their postpartum visit, and I get to the part of the visit where we talk about the pathology/autopsy results and talk about what caused the stillbirth, I will tell women, "We know that diabetics are at a high risk for stillbirth. And we know that taking your insulin regularly and showing up to have your ultrasounds and have your baby monitored decreases that risk. I see here that your blood sugars weren't well controlled and that you didn't come in for your monitoring visits. My recommendation to you, so that you don't have to go through this again, would be that you avoid pregnancy until you're able to do the things we recommend you do to decrease the risk of stillbirth. If you want to have a safe pregnancy as a diabetic, you have to do these things." At which point I launch into my contraceptive spiel and make sure they have an internist who takes care of their diabetes between pregnancies. We can never get diabetic stillbirths down to 0, but we could get them pretty low, if we had the assistance of the patients.

The thing is, this feels very much like telling the patients that their dead baby is their fault. And in many ways, it is. Telling them that seems unkind. Not telling them that seems unkind. I just worry that laying it out like that does more damage than it prevents. At the same time, I worry that not laying it out like that will do more damage. For now, I'll continue to tell them that they may have been able to prevent the stillbirth, simply because it seems like maybe the best thing for me to do is to empower them to avoid having a repeat stillbirth.

(image credit)

Random Update

2008-03-16T00:44:00.003-04:00

I will get back to medicine once of these days. Heck, if things stay as good as they are, I might never have anything interesting (even to me) to say about my gut ever again.

The UC/Crohn's disease diet is not one I would have considered "colon friendly". It's mostly about limiting insoluble fiber (lettuce, raw veggies, skins, etc) and things that could irritate your gut (pineapple, alcohol, fried food). I'm not sure where watermelon, berries, and nuts fit into these catagories (they don't seem terribly high fiber, or irritating), but they're out too. In fact, it's not a diet I would have ever thought to recommend to a patient. Limit fruits and veggies to 4-5 servings/day. 8 servings of bread (and friends) (none of which should be whole wheat). 6oz of meat or more a day (except sausage which is out). Deserts "as desired". Fats "in moderation".

And I don't know how I got so sick so fast, really. Ok, I do know, it's because my usual trigger of the otherwise innocent-appearing URI then got followed by my other usual trigger of working too darn much. The two in combination seem like a particularly powerful provoking stimulus to my dysfunctional immune system. So, then I got sick, and got sicker because I had to work even more and more to make up for the time I missed while I was sick. That apparently made my immune system angry. And you wouldn't like my immune system when it's angry. :)

This time, my extra-intestinal stuff (especially the annoying tendonitis/arthritis stuff) was actually more disabling than the intestinal manifestations. I still have a collection of erythema nodosum, but only about 4-5. They appear to be hanging around, but are really only minimally annoying.

The thing is, I am a bit angry. I'm angry that I spent almost a year feeling terrible or on 40 mg of prednisone. I'm pretty annoyed that old gi doc, instead of trying some different stuff (the UC/CD diet, which isn't magic, but may have taken me a long time to come up with on my own; or the Lialda, which is the same drug as the asacol/mesalamine but in a different formulation where it more reliably delivers the drug to my colon), just kept doing the same thing every time, despite the fact that it didn't seem to be working. I got exposed to a ton of prednisone, and had all sorts of annoying side effects from it. Now my only real side effects are insomnia (really only noticeable if I take it later in the day) and a small amount of edema (just a bit of ankle edema and a general feeling of puffiness). That's on 10mg a day. I even might be able to get away with less after I've been better for a while. Heck, with the Lialda, I might be able to get off of it and stay off of it for long periods of time. (I've spent 8 of the past 10 months on 20-40mg prednisone/day, and it sucks. I hate the mood changes, irritability, insomnia, apetite increase, puffyness, bitchyness that I get with it). And even 10mg/day minimizes side effects to a tolerable level, and reduces risk to something tolerable.

I'm angry that old gi doc never talked about what it might be reasonable to expect. I figured I might always feel at least a little sick. New gi doc says that I should expect to be able to find a way to feel well most of the time, and that I may have to put up with some stuff (the erythema nodosum can be hard to eradicate, I'll probably always have to be a little bit careful with the diet; I'm thinking I may end up making some career decisions based on allowing myself to get enough rest to feel well most of the time); but that there's no reason for me to feel so bad for so long.

And most of all, I'm angry with myself that I let old gi doc get away with it for so long! I feel like I lost 8 months of my life to Inflammatory Bowel Disease. I'm angry that I spent 10 months of my life listening to old gi doc say, "It's just UC, it's not that big of a deal, you'll be fine. Everybody goes through periods where they have more disease activity..." But it is a big deal, and I wasn't fine, and it didn't take that long to fix. But at some point, you just got to say, "Here's where I am, how do I go forward?" I guess. The other thing? I'm a doctor. They gave me all sorts of "special considerations" because of that, but I would give up all of those perqs just to have had good care.

But as much as I am angry, I'm also hopeful. Maybe the UC/IBD/Whatever it is that I have can be controlled well enough that it really won't be a big deal, most of the time.

Anyway, thanks for listening!

And PS, I have no intent to rush into a colectomy, it was just good, in a way, to hear it talked about as not the worst thing ever, anyway. Because there's almost a 50% chance I'll end up with one no matter what I do, eventually, so it had been scaring me.

New Gastroenterologist

2008-03-12T20:34:00.004-04:00

I saw the new gastroenterologist today. He might not be my ideal gastroenterologist, but it's a step up. He was at least a little more aggressive than the previous gi. I had been worried about having to explain why I'd like to transfer my care, and he didn't even ask.

He also explained some things. He explained that one of the reasons gi fellow and friends might have been confused was because my path wasn't entirely consistent with ulcerative colitis. Apparently, the scattered granulomas hiding out in my colon are somewhat suspicious for Crohn's disease, as is the fact that I loose ~10lbs/week every time I'm sick. As is the fact that anything I eat seems to reappear virtually unchanged 4 hours later. (ok, tmi, I know. Sorry) Everything else is suggestive of UC, and that's probably what I have, but... apparently it's not entirely clear.

He also decided to start me on a couple of different drugs, Lialda, which appears more effective for UC (and costs my insurance company a tidy $1600/month minus my $15 copay), a short prednisone burst to get me back into shape to get to San Diego tomorrow, and after that 10mg prednisone/day. Which is liveable.

He also started the conversation about total colectomy with J-pouch vs biologics/Imuran. He also laid out a long term plan. Try this new regimen, plus the UC/Crohn's diet (which old gi doc hadn't even shown me... it's a funny diet. Limits fruits and veggies, but deserts are to be eaten "as desired" . Clearly the people who wrote this have no idea how much I desire desert! Made me laugh.), if it isn't working ok in a month, repeat the colonoscopy to shed more light on the diagnosis, and see if it can be made certain. He seemed awfully positive about a laparoscopic colectomy with j-pouch (in fact he said he usually recommends that over the biologics/immunomodulators, because it is curative for UC,), but his doubt about whether I have UC or Crohn's Disease makes me feel like it might not be such a good idea. Although I don't really want to go there (either to the colectomy or to the biologics/immunomodulators), I appreciated that he laid the plan out for me so clearly.

The diet seems somewhat restrictive, but I plan on cheating.. I mean experimenting... once I'm better. And actually, I'm already feeling better. I've been able to eat some stuff today (and now it's certified inflamed gut friendly). And actually drink. As much as I hate it, there's nothing like prednisone for turning stuff around.

Here's hopin...

14 Pounds (Or the scale lies)

2008-03-02T18:24:00.004-05:00

That's how much weight I lost last week. Same scale, same clothes, same time of day. I'm having another UC flare, and when I do, I just completely loose my appetite. In fact, I get a weird combination of feeling extremely hungry but having zero appetite. It's a very odd feeling. Although, I am eating, some. Midmorning seems to be my window of opportunity for food. And to sneak in a little caffeine to prevent caffeiene withdrawl.

But... I was thinking about the 14 lbs. Let's say I burn 2000 kcal just going about my day (you know working, etc. Basal metabolic type stuff. I haven't been exercising. Martial arts class isn't fun if you have to run to the bathroom several times during the class. Also, it doesn't seem wise to exercise when I'm not eating much. ) And, let's say that I'm eating 500 kcal/day (I actually am probably eating more than that, but stick with me here). So.. there's a 1500 kcal difference each day. 1500 x 7 is 10,500 kcal difference each week. Each 3300 kcal you burn more than you eat is a pound of weight lost. So, 10,500 would be ~3.2 lbs. So, 14 lbs would be a 46,200 kcal difference. Or, to look at it another way, even if I ate nothing all week long, I'd only be down 14,000 kcals, which is less than 5 lbs. If I really lost 14 lbs not eating at all (which, I have been eating, just not a lot), I would have to burn 6600 kcal/day. That's like marathon-running or climbing Everest levels of physical activity, or burn-patient levels of metabolic activity, which I'm just not doing. Admittedly, work's been particularly busy as of late, but not THAT busy.

The weird thing is, I'm not really dehydrated. I keep up with my fluids pretty well. I made myself eat more yesterday, and I must have replaced my liver glycogen (for you non-docs, your liver stores sugar so that you can use it between meals), because I'm up 2 lbs from yesterday. That's another weird thing.. forcing yourself to eat. It just feels bizarre. And the scale number seems to be pretty consistent. Although I actually feel kind of puffy, so I am wondering if maybe I had a barbel in my pocket or something when I weighed myself last week. If I'm feeling this puffy, that number can't possibly be true. Actually, with the laws of thermodynamics in place, that number can't possibly be true.

If true it would be good, in a way (almost half of my prednisone pudge would be in those 12 lbs). But bad, because I have a doctors' appt on March 12 (switching docs, at long last to a nice private GI, but between his busy schedule and my busy schedule, that's the soonest I could get in). And between now and March 12, I have a trip to Toronto for a conference, and I have a trip to San Diego on March 14, and I don't have a lot of energy right now for preparing presentations, etc. for those trips. And besides, it's never good to loose 12 lbs in a week.

Anyway, just some random ponderings.

Understanding (or how work has saved my life)

2008-02-16T21:25:00.002-05:00

So, my mom was terribly ill a number of years ago. So ill that the doctors told us she wouldn't live. My mom is a tough lady and proved them wrong. My relationship with my mom has been a bit difficult. We both love each other, but she's an alcoholic, and like most alcoholics, drinking is usually very high up on her priority list.

So, anyway, mom hasn't been the same since that bout of illness. Since she was ill, she barely leaves her room. She says everything makes her too tired. Now, she doesn't work, she has no real obligations, and most days sleeps until noon (or later) gets up to her chair and watches tv. One of the reasons this frustrates me is that she's too old for her life to be that small.

So, anyway, since January, and I've noticed it more recently, I've had noticable muscle weakness, which I'm pretty certain is due to 6 months on prednisone. Steroid induced myopathy or something. Like... I have a hard time hauling my laptop around because it feels impossibly heavy. Like I dropped my laptop on the ground because my hands weren't strong enough to hold it. Like my legs get tired walking up a few stairs (before I actually get out of breath). It's actually quite annoying. It's also exhausting. I think that having reasonable muscle strength seves as a buffer against the fatigue that is part of my job. I think that having reasonable muscle strength is a buffer against a lot of fatigue. Mostly, all I want to do is rest. Not that I'm not interested in stuff. I'm enjoying the martial arts classes. Work has been interesting. I'm just exhausted all the time.

Well, I think that the combination of deconditioning and steroid myopathy is probably nothing compared to what people recovering from serious illness suffer. My mother, for example, I think never recovered from her deconditioning. Her illness occurred just after her separation from my dad, she was grieving and depressed, and couldn't find the energy to make the extra effort it takes to build muscles back. So, her body only reconditioned itself to her daily activities (sitting in a chair), and because of that, she's never had the energy to do more. And since then, her health has been worse.

One of the things that will save me is my job. My body will recondition to at least my daily activities, which include running up and down stairs (or trudging as I am today), carrying things, exercising, etc. I worry that I may not have the strength to pull a baby out, but there are chief residents and attendings (at least privates) in the hospital, so I could get help if I needed it.

But if I didn't have a job, I can see how it would be so easy just to do what I felt like doing, and that is, nothing. So, in that way, my job is a bit of a buffer against my illness. If I didn't have a job (especially if you were to throw in some depression at an inopportune time), I could easily end up like my mom, living between my chair and my bed, and having to plan a trip to the mall weeks in advance. It sort of has given me just a tiny glimpse (because I wasn't very sick) of what it is really like to recover from a serious illness with a long hospital stay, or even for our patients who need to recover from a really long time on bedrest during their pregnancies for various complications.

As it is, I'm doing ok. I'm tired, and I feel weak, but I can do what I need to do and a lot of what I want to do, although I am a little annoyed at being too tired to go to martial arts on Thursday. My internist tells me this should begin to get better once I'm off the steroids for 3-4 weeks, and to avoid a negative nitrogen (i.e. protein) balance (my carb-lust while on the prednisone may have contributed to this because I think that there were many times I didn't eat protein because I was eating carbs).

Midwife with a Fist?

2008-02-12T20:23:00.000-05:00

All right. I did it. I started martial arts training last night. I'd always thought of it as being for little kids or for mystical Asian men. But as it turns out, the list of people taking martial arts lessons can also include curious perinatologists.

It was a ton of fun. The studio that I joined teaches Moo Sool Do, which, as I understand, is an eclectic Korean martial art that's kind of a combination of Tae Kwon Do (kicking and punching, mostly) and hapkido (involves locks, throws, falls, weapons).

Why did I do such a thing? Well, I've always been at least a bit overweight, and I gained a ton of weight on the prednisone. Also, after spending 6 of the last 8 months on 20-60 mg of prednisone a day I must have lost some muscle mass. I certainly feel like I've lost some. I'm used to feeling pretty strong, but for a while, even my notebook computer has felt impossibly heavy. Carrying my groceries into my apartment has become more difficult. Also, as it turns out, strength seems to be interlaced with endurance, I think, because my (admittedly grueling) schedule has just seemed almost impossible.

Although I do indulge in self pity on occasion, I really believe that the best way to approach most problems is to find solutions, so I decided I needed some real exercise. And since we've had below zero windchills for a while (I know, I'm a wuss, but I don't jog if the windchill is below zero), I decided I needed something indoors. I tried the whole gym thing for a while, but I just get bored in a gym.

So, wandering around my neighborhood one night, I saw this place, advertising lessons. I decided I'd give it a try. It seemed interesting. And, really, I'll try anything at least once if it looks like it might be a good time.

So, I tried it. And it was fun. Apparently I'm a good puncher and a fair kicker. The teacher seemed to think that it was an accomplishment that I didn't loose my balance and fall flat on my face while learning how to do a roundhouse kick. And my arms are sore from the punching. Which feels good, mostly. I'm imagining those myocytes (muscle cells) hypertrophying.

This particular studio does contact sparring, although I have to get some more experience before I can graduate from non-contact sparring, I'm not sure I'd be able to actually hit someone. I guess I'll find out.

(picture credit)

Brrrrr!

2008-02-10T19:55:00.000-05:00

If my checkbook balance is negative, it means that I owe someone (generally, the bank) money. Since the temperarture outside is -1F (windchill is -30 F), does that mean that the weather owes me some degrees? Because it's pretty chilly, and I could really use them. It's funny, since it's that cold outside, even though my house is heated to a comfy 68F, it still feels terribly cold (the house was built in the 1910's) because of the draftyness. Even the kitties, covered in luxurious coats of fur won't get off the bed (I did leave the electric blanket on for them all day).

Brr!!

(photo credit)

Just a Reminder

2008-02-10T11:15:00.000-05:00

I had an interesting reminder when I was on call the other day. The reminder that every obstetrician needs on occaision. A cesarean section isn't necessarily atraumatic for the baby. We (the chief resident and I) did a c-section on a midwife patient. She was laboring and then pushing for a long time. The baby's head was high up. The midwife (one of my favorites) asked me to do a little consult regarding mode of delivery. I checked her, she had a condition known as deep transverse arrest: Where the baby comes into the pelvis (which they do when looking to the side because their head fits best in the pelvic inlet that way); but can't come out, at least not vaginally. People used to do forceps (Keillands and Bartons forceps were invented for this very indication) to rotate the baby and then get the baby out in this situation. I didn't train in rotational forceps, because they're so seldom done (because there's a higher risk of fetal or maternal injury if the provider makes a mistake) any more. Besides, this woman's pelvis felt small, and the baby seemed large.

That leaves really one option. C-section. Which is fine. We went back to the OR, the anesthesiologist put in a spinal, and we delivered the baby. A somewhat difficult delivery, because the baby was really stuck in the pelvis. But we got the baby out. Healthy mom, healthy baby. That's the whole goal of obstetrics. Everybody was pleased.

Except, I went to look at the baby after scrubbing out to let the chief resident and the intern finish. The baby had a cephalohematoma and some bruising from the delivery. Now, the baby will be fine, had to get some light treatment for jaundice (a common complication of a cephalohematoma), but went home with mom. The baby also had quite a bit of bruising from the delivery. I went over things in my head quite a bit, and I don't think anybody did anything wrong. We never attempted an operative vaginal delivery, she didn't push for too long, we delivered the baby as gently as you can when you're pulling a baby that's wedged into the pelvis out through the abdomen.

I think it's just one of those things that happens. It's also a good reminder that the forces of labor are powerful, and that not all birth trauma happens because of vaginal deliveries.

photo credit

I'm Back!

2008-02-04T11:27:00.000-05:00

I'm back from Dallas. I learned some interesting things. My posters were well received. I seem to have caught the plague (or maybe just a bad cold. ;) ). Rash, super sore throat, sore joints, extreme fatigue. You know... the kind of fatigue where you need a nap after taking a shower. So I emailed in sick today. I feel a little better today than I felt yesterday, so work probably won't be a problem tomorrow.

The cats were fine. Happy to see me. :) I was happy to see them.

More on the big D later. I need another nap.

Science Fair For Grown Ups!

2008-01-27T23:29:00.000-05:00

Tomorrow, I am heading off to Dallas for a Science Fair for Doctors. AKA the annual meeting of the Society for Maternal-Fetal Medicine (SMFM for short). I have 2 posters of my own, 2 posters with another fellow, and 4 posters with residents. I have been really busy this week, at work until midnight every day except Friday.

But now, my house is clean (ok, kinda clean... well... cleaner), and my stuff is packed (mostly. I'm going to let the laptop and ipod charge up over night, and I'm planning on trying to jog tomorrow, so my running shoes and running watch are out). And soon I will be sleeping. I'm on a 12:50 flight to DFW, which puts me there around 2pm, which is perfect.

A week's worth of clothes is all tightly packed into one overstuffed garment bag. I'm a little concerned that it might be over the weight limit (55 lbs per bag), so I might throw an extra bag in my car. I also have no travel-size toiletries, and forgot to make my pre-travel pilgrimage to Target, so I'm going to try to get up and do it in the morning. Since I have nothing else to do tomorrow except run, shower, and get dressed, I should be able to leave in time to buy tiny toiletries to put into little ziplock bags and throw into my carry-on. I'd prefer to put them in my checked bag, but I honestly don't think they'll fit. As it is, I had to roll up a pair of slacks and throw them in my carry-on. I never learned to pack light, but now I've learned to pack tight. Almost as good, eh? P.S. if anybody has any packing light suggestions, I'm all ears.

I also have purchased my pre-flight tunes. For this trip, it's Pearl Jam. :)

My only worry is the kitties. Everybody I know will be at the conference, leaving me nobody to check on the kitties. They should be ok for a week with a really big mixing bowl full of food, the same of water, and the tap left running. I just hate leaving them alone for so long. They always puke on my bed when I do this, and I probably deserve it.

I Think Its Done

2008-01-21T20:21:00.000-05:00

I'm heading off to a meeting in a week. I'm presenting 2 posters as the primary author, and helping a very motivated and good group of residents with their posters, for a total of 7. The posters all need to get to the printer by Wednesday. Not only that, but I'm trying to finish my thesis bench work. And call. I've been at work from 8am-midnight several days this week, and the others I've been there until 8pm. And last night I was on call. (Fun call, but sort of steady, business-wise).

And now I'm exhausted. So exausted that sitting up makes me a little nauseated and dizzy. And why does exhaustion give me insomnia? This I want to know! I have such weird sleep when I'm really tired, it takes me forever to get to sleep and I wake up a lot. I would think I'd sleep like the dead!

But it's all worth it, because everything's almost done for the meeting, my benchwork is making progress (although I kept messing stuff up today, so I went home). I'll take my posters to the printer on Wednesday, and pick them up on Thursday, just in time to fly down to Dallas, Texas. I even cleaned my house and did some laundry today.

All my exes live in Texas... ok, only one of them actually does, but I don't think I'll look her up. :)

(Image credit)

Decision Appears to be Made

2008-01-19T18:57:00.000-05:00

I appreciate everybody's input about the PhD decision. At first, I was sure I was going to do it. I even put things into place to start figuring out the mechanics of doing it. I was offered a junior faculty position for the time it took me to complete it. I was all excited about it, and then I started to think.... a PhD usually takes 3-5 years even when the student does nothing but their PhD work, and although my medical school stuff would count for a lot of PhD work, I really feel like if I got one in a year, it would likely be sort of a rubber stamp PhD, and I'm not interested in that. I respect what real scientists do too much for that.

The other thing is, while I'm having fun doing my thesis work right now (the work is going well, and things are always more fun when you're successful), I do miss patient care. And medicine is what I love about medicine. I think I could be good at research, but I'd never really love it enough to make up for the time I didn't spend taking care of patients.

And then I got a job offer. From a very smart guy. Who seems to respect me. He asked me to be the dirctor of (something) in a different city, far far away. He said that I was the person and the doctor he wanted, and he was happy to wait a year and a half for me to finish my fellowship if it meant he could have me. Also, he was very non-pushy about it. He specifically told me I should look at other jobs, come and see the place in the different city. He said that he cared about my happiness, and if I thought I'd be happier in another place I should go there, but that again, I'm the doctor he wants to be the director of that thing in that city, so he'd appreciate it if I'd at least consider it, and make a trip out to see the place sometime in the summer or fall. I can't give details, but lets just say that for the first year out, getting to be director of that thing is very complementary. Also, he offered me a lab, sort of as a play-thing to get me to go there.

This made me realize a couple of things. First of all, I would love being that person that was the director of that thing in that city. Also, I don't want bench science to be my hobby, it's too important and way too expensive to just be a hobby. Thirdly, trying to give 100% to research and 100% to medicine is too many percents!

So, I probably won't go to PhD school. Now I just have to figure out how to explain that to the bigwigs at my program that although I told them I was interested, I've really decided it's probably not the right thing for me.

Anybody Care to Make My Life-Altering Decisions for Me?

2008-01-09T14:48:00.000-05:00

I was recently offered the opportunity to spend an extra year in my current position and earn a PhD. It's very tempting. And a year really isn't that long.

Also, a PhD is quite handy on the CV.

But a year is kind of a long time at the same time because sometimes I hate it here and it is a long way from friends and family. I bet that a PhD doesn't involve a lot of naps, either.

Decisions, decisions. Maybe I'll just flip a coin.

Complementary and Alternative Medicine

2007-12-29T20:21:00.001-05:00

I was watching an old edition of Frontline:World that I had on my DVR. The one about CIA rendition of terrorism suspects to other countries for torture... excuse me, I mean alternative means of interrogation.

Anyway, the next segment on this episode was about Ayurveda, a form of traditional Indian medicine. The reporter goes to an Indian Ayurvedic retreat with a frozen shoulder maybe, or maybe severe osteoarthritis of his shoulder. He'd been offered a shoulder replacement surgery by an orthopedic surgeon, but was trying to explore non-surgical remedies. His shoulder ailment was relatively severe, in that he didn't have enough movement in his shoulder to comb his hair.

So, anyway, he spends (I think) 2 weeks at this Ayurvedic spa/hospital getting his Doshes balanced with various noxious potions (judging by his descriptions), massages, anointings. Also he got daily shoulder exercises and daily shoulder massages.

Surprisingly (or not, really), his shoulder got better. At the end, he credits this to Ayurvedic medicine.

I'm not a believer in complementary and alternative medicine. At all.

Except, I am. Kind of. But not really.

Let me explain. I don't really believe in Doshes or in homeopathy and the memory of water, aligning chi, or any of that stuff. I'm not a big believer in the supernatural.

I think that Western medicine (hereafter known simply as medicine) is great at curing acute illnesses. Accupuncture/Ayurveda will never be widely promoted for curing tuberculosis or meningitis, or for healing traumatic injuries. What we don't learn in medical school is much about promoting and maintaining health. Western culture also doesn't promote a lifestyle conducive to health. Additionally, what used to be common sense with respect to health is no longer so common.

Many, many people don't have time to cook their own food on a regular basis due in part to work demands and also in part to long commutes. The average commute in the metropolitan area I live in is something like 45 minutes each way. That's 1.5 hours each day. So, if people could afford to live near where they worked, and had a 30 minute commute, that 60 minutes would be enough time to either cook dinner or to get the exercise they need that day. Or, if they lived a 20-30 minute walk away from work, they could just use that extra 45 minutes to cook dinner.

Additionally, most (almost all) of my patients live in the grocery desert known as the inner city (seriously, you can't buy produce within 6 miles of the hospital I work at!). So, they live on fast food. Church's chicken, McDonald's hamburgers, Wendy's, that sort of thing. And the hospital isn't helping much by having an expensive cafeteria with very limited hours, and making Wendy's the only food that's either available or affordable to most of their patients and employees. Is it any wonder we have so much hypertension, obesity, etc? I mean, a certain percentage of the population will always be hypertensive and/or obese and/or diabetic. It does seem though, that those with the genetic predisposition to those diseases who happen to live in the inner city and be poor don't really have a fighting chance.

So, back to the story. You take this reporter with a bad shoulder, feed him good food, let him rest, have him do daily exercises and get daily massages on this shoulder, and what do you get? It's basically intensive physical therapy, which we know works. Why don't we do this here? Because it takes a lot of time and money. The guy didn't continue with the exercises as he was told to do, and his shoulder got worse again. So, I don't think it was Ayurveda balancing his Doshes that fixed his shoulder. It was the rest and intensive physical therapy. What Ayurveda really offered him was wellness.

And what he failed to continue to do was maintain his wellness. So, although I don't think that people have Doshes that need balancing or chi that needs redirecting, I do think that some of these traditional systems of medicine may have a thing or two to say about maintaining wellness that we in western culture (particularly in the USA) seem to have forgotten along the way.

(Picture Credit)

Push Any Button To Rock!

2007-12-29T14:55:00.000-05:00

I have to say that Guitar Hero III is definately a winner! It's a lot of fun. More fun with a crowd, but definately fun on your own.

My only complaint (and it's a small one) is that the difficulty increase between easy and medium is a bit steep. I can beat all the songs the first time on easy, but medium is a lot more difficult than easy, but the hard and expert settings, while being an increase in difficulty aren't THAT much harder. Oh, and the other criticism: Extra guitars are a bit expensive, and you have to buy an additional Wii-mote to use them.

It's got good songs, a funny plastic guitar, and amusing animated cut scenes.

The game is innovative, a bit different from the parade of platformers, first person shooters, etc (nothing against Mario and Halo, mind you, but they've been around for 10-20 years (I think Mario Brothers first came out in 1985) ). I'd highly recommend Guitar Hero.

And just remember, if the music's too loud, you're too old. ;)

A Note To Hospitals

2007-12-27T19:52:00.000-05:00

Now that many of my friends are attendings (aka real doctors) while I'm still a fellow (aka a pretending), something is becoming clear to me. Hospitals need doctors at least as much (probably more) than doctors need hospitals. If a hospital makes its doctors' professional lives unbearable by implementing various gimmicks from the business world ("lean thinking", customer service, etc.), doctors can take their patients to another hospital. In general, patients are more attached to their doctors than to any particular hospital.

I can practice in any hospital that has operating rooms, anesthesiologists, and an ultrasound available for me. Therefore, any hospital that makes me do computerized learning modules about how "Customer service is our number 1 priority" can simply go away, once I graduate.

For the record, customer service is not my "number 1 priority". Providing excellent obstetric care is my number one priority. My patients mostly seem to want disability for life, unlimited vicodin and ativan (and then they'll want to sue me when their kid doesn't go to Harvard). If I were all about customer service, I would simply give them what they ask for. Giving the customer what they want is good customer service. It isn't always good medical care, though. I will prioritize good medical care over good customer service every time.

This Ends Now

2007-12-27T16:35:00.000-05:00

After having spent 5 days sleeping 12-14 hours/day and eating buckets of chocolate (although still exercising), I have to say that this ends now. I will clean my apartment, I will get out and do some shopping, and I will start getting up at a reasonable hour. I am on call at 8am on 12/30, and I must be able to get out of bed that morning. I also must continue to fit into my clothes.

So.

THIS

ENDS

NOW.

Felines Navidad!

2007-12-24T19:22:00.000-05:00

My cats want to wish you a Merry Christmas/Happy Holidays/Festivus/Solstice/Whatever

Cat Blogging Part 1: Who Are these Cats Anyway?

2007-12-23T16:13:00.000-05:00

This post brought to you in part by Carribou Coffee, since I'll be without power through the night. The cats now have another job... keeping my bed warm.

OK, so the cats are always asking why I don't blog about them more. They are, they say, the most interesting thing going on in my life at any one time. So, I thought I'd show some pictures of the kitties and introduce you all to them. Essentially both of them came into my life because I'm a bit of a sucker for a sad story. However, I've been very glad to have them. :)

This is Ron. He's a domestic short-haired tabby. Neutered, indoor only (except when he escapes, which he only tries in the summer). Quite a hunter, when I lived in an apartment with a mouse problem, he would capture mice on a regular basis. The only thing is, since he was an orphan, he didn't quite know what to do with the things. So, he gave them to me.

He acquired me the summer before medical school, when he was 2-3 weeks old. His mother (a feral barn cat) had been killed in a showdown with a car, and the owner of the barn that Ron's mom (aka Large Marge) lived in asked me if I could bottle feed Ron until he was weanable (probably about 2 weeks). So, being a sucker for orphans and such, I said yes. The guy said he would find Ron a home after he was weaned, and that I was under no obligation to keep the kitten (as I was getting ready to move and all). The thing is, baby kittens need to be bottle fed several times a day. So, I took Ron home with me, and he slept in my bedroom (OK, actually in my hair) between feedings. The other thing is, you can't bottle feed a baby kitten for 3 weeks and then give it back. So, when said friend was offering to find a home for Ron, I said, "Um. no.... that's ok, he already has one." And he's remained with me ever since. He's a big cat, last weight was 22 lbs, but he's not fat. The fat cat is the next one. ;) He's now about 10 years old now, and my life is much better with him than it would have been without him.

This is Sylvester. (Source of the name is obvious, no?). He was originally my roommate's cat. The thing about that particular roommate is that he had schizoaffective disorder. Mostly he was nice when he was well, but sometimes he was mean (when he was ill), and sometimes he would break things and kick the cat. Or yell at the cat. And this cat had been rescued from previous abuse which included a partial tail amputation. And Sylvester is a nice cat. All he needs is love.

So, when I decided enough was enough and that I needed my own apartment, I simply took the cat with me. I told my roomate he couldn't have him back (I know that sounds kind of mean, but....). And Sylvester has the most gentle, most loving temperament. He also loves to eat. In fact, when he was in renal failure from a bladder obstruction and taking valium to help relieve the bladder obstruction (muscle relaxant properties, as well as to decrease his anxiety about urination in general), he would attempt to eat rocks. Talk about a serious case of the munchies!
I've tried putting him on diets, but he starts to look too sad. So, I think he just is how he is, and his 28lb weight is just going to be what it is.

These are the cats!

I Made It!

2007-12-23T12:20:00.000-05:00

Grant proposal: Done
Class: Passed
Call: Done through 12/30
Thesis project: Not done, will it ever be? ;)
Clinic responsibilities: Done (through April).

After 3 100-hour work weeks, I have completed the necessary things to allow me to take a vacation. YAY!

I suppose that leaves me with nothing to do but take a week off over Christmas, blog, and play with my Wii.

I'm trying to convince myself to clean my apartment today, to do laundry, etc. But what I really want to do is lie down with the kitties and nap. That's what they want me to do, too. Sometimes the cats know best. I will post a real post when I wake up in a few days. ;) Or maybe I'll post embarassing pictures of my cats. *evil laugh*

Happy holidays, everybody!

(image credit... It's not one of my cats, but if they don't watch out...)

Ouch

2007-12-16T17:54:00.000-05:00

I accidentally crippled myself today. I awoke with a sore left shoulder/neck. I think just a trapezius muscle spasm (maybe I slept on it funny).

Then I shoveled myself out of a foot of fresh snow. It took over an hour of shovelling. I enjoyed it, actually (it was my jogging substitute). I walked about a mile through the new snow into the little village area and bought some eggs, had a pepermint mocha, and a nice stroll through the clean, fresh snow. My shoulder felt better, but now it really hurts. I don't even know that I can do my dishes. Just carrying them to the sink was painful. I also wanted to clean my house, bake a coffee cake and do my laundry. Even my usual awesome cocktail of 1000mg tylenol + 800mg ibuprofen didn't make it much better.

I think I'll just take out the trash, finish the laundry, and take a hot bath and go to bed early. Maybe in the morning I'll be able to throw the coffee cake together.

I think I'm just not good with pain. I find it extremely uncomfortable. It makes me want to do things like seek heat and rest.

(image credit)

Things that make you go ARGH!!!

2007-12-16T15:39:00.001-05:00

I take a folic acid supplement. Not that I'm planning on becoming pregnant any time soon, but I did get a bit anemic a while back, and apparently Asacol interferes with gut folate absorption.

Anyway, I just happened to read the bottle on the folic acid I bought at CVS, and it states that pregnant women should "discontinue this medication and consult your doctor".

Dear pregnant women: If you become pregnant while on folic acid, please do not discontinue it (at least not until you're a good 8-10 weeks along), and please do not let this warning stress you out.

Folic acid is GOOOD in pregnancy. It prevents neural tube defects. It will not harm your baby.

Dear CVS: You're stupid.

Grades Don't Matter, Except When They Do

2007-12-15T20:20:00.001-05:00

I have been called upon to interview some residency candidates this interview season. It's actually a job that I like. It gives me some illusion that I have some input into determining the residents I'm going to teach to be obstetricians.

And a little secret I'm going to let you know from this experience? Grades don't matter, except when they do.

Now, I'm a firm believer that good grades won't guarentee that you'll be a good doctor, and mediocre grades don't correlate with being a mediocre doctor. But you know what? You need to pass all of your classes. If you're dismissed for poor academic performance, you need to have a reason. Like, maybe you or your husband or wife or child had cancer or something. If you fail your peds rotation, likewise, you need a good excuse. Your excuse can not be, "My sister was visiting from San Francisco and she's kind of high maintenence.". And even if you don't have a good excuse, when your interviewer asks you what you learned from this experience, you should have something real and concrete. Like, "I wasn't prepared for the kind of learning situation in medical school, but I figured it out after having a lot of problems the first semester." Don't just laugh. And all of your 1000 extracurricular activities won't help you, you see, they will really just make me wonder about your ability to prioritize. And if you fail your first year of medical school and your pediatrics rotation, you need to do really well on your USMLEs. Passing with 1 point to spare isn't well enough.

Traditionally, allopathic US grads have an advantage over foreign grads and osteopathic applicants in gaining admission to allopathic residencies (not to say that they're any less qualified than allopathic US grads, but they're at a disadvantage when they apply). But I'll tell you this. If you fail all over the place like that, I would rather our program go unfilled than take you. And if you fail all over the place like that, I'll definitely pick a well prepared osteopathic graduate or foreign graduate over you.

And I'll tell you why.

Sure, grades aren't everything. I wasn't the biggest academic superstar in my medical school class (I was somewhere on the good side of mediocre, you know, good, but not AOA good, and made up for it with a 235 and a 254 on USMLE Steps I and II). And like I said before, good grades aren't the same thing as good doctor. But medicine is, in part, a profession of learning. Medicine (basically all fields) change pretty much constantly, so you need to be able to pick up and assimilate new information. Admittedly, good test scores mostly say that you're good at taking tests, but here's the thing. At the end of residency, you have to take the boards, which is a written exam. The Ob-gyn boards aren't terribly difficult, but they're a bit more challenging than the USMLE. Even well prepared candidates sometimes fail them. You also have to take tests throughout residency, known as in-service exams (CREOG for ob-gyn).

If you can't pass the boards, there's no point in my bothering to train you, really. And if you can't pass medical school classes reliably, and barely pass the USMLE, than I don't really have any reason to think that you can pass the boards. I know this sounds harsh, but it's true.

So, although when I'm interviewing and ranking candidates, I don't really care too much about grades (although I'll put a candidate with great grades above the equivalent candidate with mediocre grades), you really really have to pass. I also think that finding a way to pass medical school shows some dedication to the field. If you allow yourself to fail peds because you have house guests, forgive me if I question your commitment to being a doctor. I mean, what if I didn't prepare for surgery because I had house guests? The patient would suffer, and that's not appropriate. Even if I have a really special occasion, I can't drink so much I show up to work hung over, although, maybe if I was in a different profession, I could. Sometimes medicine has to come first, and in medical school, medicine really has to be a high priority in your life. It doesn't always have to come FIRST, but it always has to be towards the top of the list. If you're not able to deal with that, maybe you should find another profession.

It may sound harsh, but it's the way it is. So study hard, and pass. And if you want to do ortho, derm, or another really competitive residency, you better do better than just pass. But for OB, passing is (just barely) good enough. There are less competitive residencies which routinely don't fill, particularly in internal medicine (because there are just so many programs) and family practice (again a lot of programs, and waning popularity); but I'm not suggesting that people who can't pass medical school do those residencies. Internal medicine and family practice are very difficult and require a huge amount of lifelong learning. And I suspect (ok, actually, I know) they also have board exams that must be passed. I'm suggesting that if you're not dedicated enough to figure out where the lesion is (the one that's keeping you from passing) and do something about it, you need to find something else to do with your life.

(Image credit)

Wow

2007-12-15T18:42:00.000-05:00

I have now officially gone 3 weeks without any abdominal pain, and 2 weeks since the last of my joint pain went away. I really really love not having pain. Not having pain is like.. the best thing ever. Every morning for the last two weeks I've awakened and thought, "I don't hurt. This is so cool!".

The weird chills/fevers have gone away. Even the fatigue is pretty much gone. I don't think I've felt this good in a year. (And I think I was sick for a lot longer than I realized. I think I first started to get sick with the UC a year ago, but ignored it for a few months until I got REALLY sick and showed up at my internists office stating I thought I'd given myself salmonella and couldn't figure out how to choose an antibiotic. I'd planned on trying a quinolone, and she wisely stopped me, tried to admit me to the hospital, and I ...um.... declined. ;) From there, the rest is, as they say, history).

And, now as I taper the prednisone (on the world's most excruciatingly slow taper ever), some of the more annoying side effects from that are getting better. That weird super hungry pressure to eat is easing off now that I'm down to 20-30 (altrenating), the irritability is better (even my clothes were annoying me!), the mood swings are better, even the insomnia is improving (partly because I'm not waking up starving, and partly because I've given in and decided to let myself take Ambien a little more often, and I think partly because the prednisone dose is lower).

I know that this all sounds dumb, and maybe it is, but it's still true.

Retail Therapy

2007-12-09T17:20:00.000-05:00

I had some shopping to do. I also was a little bit down today. Not that anything bad has happened, I think it has more to do with being in the middle of an 8 day stretch of every other night call, and I haven't been lucky with my calls. I have literally been working for 24-30 hours straight every other day. And although my energy is a bit better (probably has something to do with the UC being in remission for a week and a half now), it's just exhausting. Especially since the prednisone is still disrupting my sleep.

Anyway, it is amazing how sometimes getting new stuff (even when it's stuff I need) can sort of cheer me up. I'm not really a shopper at heart, but I was pleased with what I bought.

And the list?

New running shoes (mine were a year old, way past time to replace them)
New running socks (who'd've guessed they made special socks just for running in... I bet they'll make me look thin, feel thin, and run fast. Or... they'll simply provide a barrier between my shoes and my feet. ;) )
New meat thermometer
Kitchen Twine
Light blue cashmere sweater (on sale for 1/2 off from Macy's. Hey, "Tim Gunn's guide to style" says that every woman needs a cashmere sweater)
Assorted chocolate truffles shaped like penguins and pyramids and stuff from moonstruck chocolates

So, tonight, I'm going to cook a chicken using the thermometer and twine. Tomorrow, I'll go jogging in the new shoes (breaking them in by wearing them around the house this afternoon). I'll wear the cashmere sweater (as well as some black slacks and white blouse) to work tomorrow, and since I'm on call again tomorrow night, I'll take a truffle with me.

It all sounds extravagant, but really, it will all be used.

New Tension Headache Cure

2007-12-08T23:24:00.000-05:00

My favorite new tension headache cure is hot cocoa accompanied by hand-made marshmallows and a purring kitty. Followed by a nap. Guaranteed to feel better when you wake up, or your money back.

Warning: Side effects include drowsiness, insomnia, allergic rhinitis, obesity, and excessive cuddliness. New Tension Headache Cure may not be appropriate for all patients. Call your doctor if you think you are having an adverse reaction to New Tension Headache Cure. New Tension Headache Cure is not approved for the relief of tension headaches by the FDA.

:)

Drive by Post about Jogging

2007-12-05T14:02:00.000-05:00

Does the fact that I enjoyed my jog this morning make me crazy?

It was 5:30am.

And snowing.

And 15F.

Everybody tells me I should jog indoors on a track or a treadmill.... but there's something really nice about being outside, even if it is dark... and cold... and snowing.

Am I going to become a nutty jogger? Or just a normal one?

As an aside, it's funny how once you make a point to make something a habbit, you sometimes even start to enjoy it.

Winter's Here!

2007-12-02T11:16:00.000-05:00

Winter has arrived in the Midwest. I was going to get up and do stuff this morning, but the grey snowscape (and freezing rain!) inspired me to do otherwise. Right now, I'm having a relaxing morning with the cats, who are appreciating the new electric blanket.

I've lived a bunch of different places in and outside the U.S. While the pacific northwest may be my favorite, upstate New York and the Midwest are close seconds. One thing they do better than the northwest is seasons. Seattle doesn't really have four distinct seasons. Winter blends rather seamlessly into summer, spring is obvious mostly in retrospect. I'd say that Seattle has 3 seasons. Alaska has four seasons, and is my absolute favorite place I've ever lived (I'm plotting a strategy to get back there). The Midwest has 4 very distinct seasons. You can actually pinpoint the first day that was autumn rather than summer. And there's a sharp break point between winter and autumn (which happens to have been yesterday!), as well as between spring and winter. That's kind of neat. Now, if only there were conveniently located mountains and ocean, the Midwest would be perfect!

But today, I'll do my laundry, clean out the DVR, and maybe write a blog post or two (I picked up a copy of "Maternity Today" at Whole Foods a while back and I've been meaning to comment on a few things), and enjoy winter from the comfort of my couch while the cats lounge on the electric blanket which I don't have the heart to turn off this morning because they love it so.

The one thing I'm not going to do today is go to work. I have a new rule. Let's call it a Veteran's Day resolution? I will take 1 day, 1 24 hour day, each week where I don't go to work. I can catch up on laundry, exercise, nap, eat yummy food, watch tv, anything but go to work. The thing about it is, taking a day off a week seems to have made me more productive during the rest of the week. :) I highly recommend days off.

(Image credit)

2000 Miles

2007-11-29T19:25:00.001-05:00

Forgive this departure into my family life (in fact, skip it if you want to!).

So, after not having been home for Thanksgiving in years, and after having been painfully alone last Thanksgiving, I decided to go home for Thanksgiving this year. It's a 2000 mile trip, plus the several hundred miles I drove to see friends other places.

So the thing about me going home is that... well... my family is a bit crazy. Nothing worse than the average alcoholic mother, bipolar aunt kinda stuff. And don't misunderstand me, I love them (even the crazy ones), but they're not what one would call relaxing. I do have to admit though that once I realized that their problems are not my problems, and not anything I'm going to be able to change, it did get less stressful (For the record, I was almost 30 when I had that epiphany. I'm a slow learner). And really, my mom's not evil (my aunt may be... I haven't decided), she's just a little needy, a little intrusive, and a little manipulative. In her way, she really loves me. She just isn't good at dealing with reality on its own terms. She does make me sad though, because her health isn't so good, and I don't think she's ever really going to do the things she needs to do to take care of herself.

A friend of mine came with me for dinner. In my defense, I totally warned her that although the food would be good, my sibs would be cool, my mom and aunt are kind of crazy alcoholics who will only take medicines on a recreational basis. She tolerated a good 10 hours of crazy time with my family before asking me to take her home (our plan had been to spend the night at my mom's house). So I did. Other than the fact that it was 1am, it was a fun drive.

The next morning I spent with my little brother and little sister. They were the saving grace and highlight of the trip! We went for yummy donuts and yummy coffee and sat and chatted.

That evening I drove a few hundred miles to visit with my brother and his wife. We went to a bunch of tiny boutique chocolate stores. I am nibbling my way through gourmet chocolates. I love chocolate. The thing about quality chocolate is that it really makes you feel good in a way that Hershey's just doesn't (or, it does, but you have to eat tons of it! and then it makes your tummy hurt). So, we spent that night, and I've spent much of this week in a chocolate induced haze. A very pleasant little haze. Nothing in the world can be bad when you have a chocolate buzz. :)

I spent a total of 4 days on vacation. And although there was the usual family stress stuff, it was a lot of fun. Completely exhausting, and tinged with sadness, but fun. I actually wish I'd spent more time there. Next time, I think I'll just take the whole week off. Or maybe 2 weeks, one for my family, one to recover. :)

Back to the chocolate. Tonight, it's "Mo's Bacon Bar!" Mmmm... smokey baconey goodness with chocolate. Gotta love it!

(image credit)

Happy Thanksgiving!

2007-11-20T10:35:00.000-05:00

I'm heading out for 4 days of relaxation with friends and family in about 24 hours. I don't know if I'll get much blogging done while I'm away, but I just wanted to wish everybody a happy Thanksgiving (and if you're not an American, have a great week/weekend/happy Thursday!).

I'm thankful for my blog, and the blog-readers. :)

Sometimes Enough is Enough

2007-11-17T18:17:00.000-05:00

I was on call last night, and it was pretty busy. 3 c-sections, 10 vaginal deliveries, evacuation of a postpartum vaginal hematoma (big! There was a liter of blood in there!) a cornual ectopic pregnancy, and a partridge in a pear tree!

Anyway, between all of that running around, I had a miniature epiphany, of sorts. Sometimes, enough is enough. I'd been torturing myself trying to decide whether I should register for my oral ob-gyn boards this year and take them next, or if I should wait a year or two. There's very little real consequence for taking them a little later, and in fact, most people take them their second year out in practice.

The reason to take them would be that part of me would like to have it done. At the same time, I've got a lot going on right now. I almost failed my medical genetics test; I had seven papers accepted for a meeting in late January/early February; I had a paper accepted at a meeting (in sunny San Diego! in March! What a nice little trip!), and I'm a finalist for an award for that one; I haven't been feeling great, but hopefully a few months from now, I will be.

And I just found myself thinking that I didn't really want to add studying for my oral boards on to my to do list for the year. If I were to take them and fail, there's little consequence (except the fact that they cost ~$2000 to take, and that's a fair chunk of change).

Really, I just want to get well, work on my research and go to meetings this year, as well as continue with my pottery, take some tae kwon do lessons, pass my class, finish my thesis project research, and do my teaching and clinical stuff. I think that I've decided, if I get all of that accomplished in the next year, that will be enough. And sometimes, enough is enough.