Apparently I’m not the only person who thinks that psychiatrists don’t know what they’re talking about. The following is a bill that passed through the New Mexico senate in 1995, only to be later vetoed by the governor:
When a psychologist or psychiatrist testifies during a defendant’s competency hearing, the psychologist or psychiatrist shall wear a cone-shaped hat that is not less than two feet tall. The surface of the hat shall be imprinted with stars and lightning bolts.
Additionally, a psychologist or psychiatrist shall be required to don a white beard that is not less than 18 inches in length, and shall punctuate crucial elements of his testimony by stabbing the air with a wand.
Whenever a psychologist or psychiatrist provides expert testimony regarding a defendant’s competency, the bailiff shall contemporaneously dim the courtroom lights and administer two strikes to a Chinese gong.
A necessary part of running a hospital involves the task of getting everything paid for. In the United States, we use a complex series of codes called ICD-9 to bill insurance companies based upon which disease is treated. In psychiatry, all patients are given a diagnosis based upon the DSM-IV (The Diagnostic and Statistical Manual), the handbook of the American Psychiatric Association. For those of you who are unaware, the DSM-IV reads like a checklist. A typical diagnosis falling under the heading of “major depressive disorder” will list a series of criteria defining the diagnosis based on everything from decreased sleep to loss of interest in hobbies. If a person meets these criteria, then he is considered depressed. The problem arises when the patient doesn’t necessarily fit all the conditions. For example, in major depressive disorder, there are four criteria which must be met. If a patient only meets three of them, he cannot be diagnosed with MDD—no matter how sad he feels.
On my ward, everyone gets a diagnosis and a prescription upon admission. As my attending once told us, “We need a diagnosis. Give me something to put down here.” We then proceeded to force a patient into a category known as “psychosis, not otherwise specified” or anything else that might get us paid. My attending uses a fudge factor to try to force anyone to a diagnosis. To qualify for the label of “psychosis,” a person must have either delusions or hallucinations. When we interview someone in the psychiatry office, the patient is often intrigued by all of the posters on the walls. He may begin looking around the room and reading whatever is posted. Our attending will then use this behavior as evidence of hallucinations by saying, “He’s looking for the voices.”
I’m starting to size up the people around me and trying to fit them into psychiatric categories. My first diagnosis is for my attending, who I’m sure has narcissistic personality disorder. He sits in a high-back leather executive chair during rounds, while the rest of us sit in plastic seats. He begins rounds each day by methodically counting all of the patients’ charts as well as all of the medical students and residents present. We then discuss the new patients of the day, most of whom have schizophrenia.
Schizophrenia is the most devastating disease known to man, with the loss of employment, little hope for education, difficulty in maintaining interpersonal relationships, and the general trend of a downward spiral to the point where the patient is no longer functional. Many schizophrenics are forced to go on disability and receive Social Security income from the government. Many other schizophrenics turn to alcohol and drug abuse as a coping mechanism. When we combine these two, we get patients who are purchasing drugs using tax payers’ money. As one man told us of his cocaine habit, I could hear a sucking sound coming from the Social Security Administration that paid for his expensive addiction.
There are many conditions which resemble schizophrenia: drugs, certain infections, and traumatic brain injury. These diseases can lead to a variety of hard to handle behavior as witnessed this past week when an HIV-positive woman came into the staff area of the psychiatric hospital and then urinated all over the floor. As one physician stated, “Who needs TV when there’s drama here?” True, I do see a lot of crazy stuff.
I started inpatient psychiatry this week, which is already turning out to be one of the most ridiculous clinical settings I’ve ever been in—for a variety of reasons. My very first patient of the day was a 40-year-old man who claimed that he was 10 1/2 months pregnant. He was fairly certain that he was going to give birth in the next two weeks, claiming that he was carrying 50 babies. He was very adamant that he was the mother of the children and that his cousin was the father, prompting my attending to say, “That’s the craziest fucking shit I’ve ever seen in my 20 years in psychiatry.”
I certainly expect odd behavior from my patients. However, I’m sorry to see that many of the psychiatry residents and attendings also exhibit severe personality flaws. Already in my second day, I’ve diagnosed my intern as being manic. He told us on the wards that he was a player, and then proceeded to hit on a social worker, two pharmacy students, and was even flirting with several of the committed patients. I’m pretty sure that he’s going to be one of those psychiatry residents who ends up marrying a patient.
He talks incessantly. He tells us that he’s such a wonderful teacher, and then proceeds to read to us from a PowerPoint slide. While the med students are diligently writing notes and filing them away in patients’ charts, he is idling his time by surfing Facebook.com and telling us, “This is such a hard rotation. I can’t believe the amount of work I have to put in.” I wonder how a person who lacks insight and judgment got put in charge of managing a dozen patients who also lack insight and judgment.
Probably the most offensive thing I’ve had to witness so far on this rotation is the dress code. Nothing seems more out of place that a psychiatrist who wears a white coat. As if they’re real doctors! The pockets are typically empty. There is never a stethoscope, a reflex hammer, penlight, or anything else that might make a person believe that psychiatrists practice any kind of real medicine. My service consults out for every medical problem: diabetes, hypertension, shin pain, and pregnant men. Then, the shrinks all get upset and offended when other specialties state that they aren’t real doctors.
But I think I may have found a woman for my intern. I was sitting in on an interview today when the patient stopped addressing my partner, turned to me, and said, “Hey handsome, if you give me 69, I give you 69. You can get me pregnant.” Seems like a perfect match to me.
I finally wrapped up pediatrics this weekend. Throughout the previous two months I’ve seen and done things I’ve never thought possible. I’ve also learned quite a bit about children, mostly in the form of questioning the bizarre behavior that I saw around me. I would like to take this opportunity to share some of those questions and their answers with my reading audience.
Question: When I was in the neonatal ICU I noticed that all of the doctors and nurses were wearing gloves when handling the infants. While I understand that hand washing is good for reducing the spread of infections, why are gloves also necessary?
Answer: the purpose of the gloves is not to reduce the spread of infection; it’s to prevent the scent on your hands from being transferred to the infant. If the mother smells the scent of another creature on her baby, she will immediately kill and eat her child. It happens all the time in nature. Since were trying to prevent this from ever occurring, it’s necessary that all doctors and nurses wear gloves when handling babies.
Question: What are our responsibilities on pediatrics? What happens when we don’t fulfill those responsibilities?
Answer: As Pandabear is fond of saying, you have no true responsibilities as a medical student. However, the university will certainly try to give you many pretend responsibilities. I had to take call every fourth night to admit patients and to help the residents with their work. On two separate occasions I had forgotten that I was on call, gone home, and taken a nap. Each time I woke up, realized that I was supposed to be in the hospital, and then ran back to the wards. On both occasions, despite being late by several hours, the residents took no notice of my absence. In one case, the resident even said, “I didn’t even know med students took call.” The good news is that I’m on the psychiatry as my next rotation. I figure that if I’m ever late, I’ll tell the patient, “You had better tell everyone that I was here at 2 p.m.” If he ever squeals and tells my attending that I showed up at six, I’ll reply, “He’s crazy! Obviously he doesn’t know what time I arrived.”
Question: I watched a doctor give a lecture via PowerPoint today. He seemed not to know how the computer worked. He had the presentation in “edit” mode and went through the entire lecture with the screen at only half size. Why is it that doctors don’t know much about technology?
Answer: Nothing scares me more than physicians who don’t understand computers. Doctors are supposed to be the best and brightest of our nation; however, many of them can’t figure out how to use a microwave if their life depended on it. I’m constantly amazed at how we have many medical advances such as lasers being used in surgery, molecular mapping of the human genome, and nano robots that can deliver drugs to pinpoint target. Despite all these advances in technology, many physicians are scared of using anything technologically-related. Many of the premeds who used to shun physics, math, and engineering courses as undergraduates eventually progressed into becoming physicians who also shun applied physics, applied mathematics, and applied engineering. I’m extremely annoyed that we continue to use paper-based charts for all of our patients. My hospital has tried to go into a quasi-computer method of charting patients. We use electronic medical records to house data such as x-rays and laboratory results. However, we continue to use paper charts for admission notes and record-keeping. Once the patient is discharged and returns to clinic a week later, we no longer have access to the paper charts. Therefore, we have no idea why the patient is coming for a follow-up appointment. And forget about the patient ever knowing why they’re there. Most of them will merely reply, “I got a letter in the mail telling me to show up today.”
Question: Why do pediatricians talk to everyone (including adults) like children?
Answer: Doctors only understand what they practice—and pediatricians are no exception. One of my many great annoyances from this past rotation—and believe me, there were a lot—included pediatricians to like to talk to me as if I were a five-year-old. Nothing is worse than having a resident who is younger than me adopt a high-pitched voice and then say, “Do you think you can get that done for us?” Lord, I can’t imagine what their consults are like.
Since I’m starting psychiatry tomorrow, I’m sure I’ll have lots of new stories to begin posting on this blog. I’m sure many of them will begin with, “You won’t believe the shit I saw today!”
As I continue through the pediatrics rotation, I’ve been thrust into the emergency department so that I can enjoy the faster paced side of this field. One of the problems with my school is that medical students are only assigned low acuity cases. I can see paramedics roll a 10-year-old down the hall who is seizing and get to watch in awe as the residents proceed to take over and run the case. While I’m enjoying the show, an attending will invariably tell me, “Okay, it’s time for you to go check on that kid with a running nose.”
While I love emergency medicine and think that I might want to pursue it as a career, pediatric EM certainly makes me want to go running and screaming in the other direction. I had a mother come in this week with all three of her children registered as patients. Patient #1′s complaint: cough. Patient #2′s complaint: sneeze. Patient #3′s complaint: watery eyes. I asked the mother why all three of the children had to be brought to the emergency department. She replied, “They had today off of school, so I figured I would bring them all in to get checked out.”
There are two routes to becoming board-certified in pediatric emergency medicine. The first method is to go through residency in emergency medicine, and then pursue subspecialty training and pediatric EM. The second method is to do pediatrics first, and then pursue an emergency medicine fellowship. I can always tell who took the EM route based solely on their sense of humor. If one of our cold and flu patients is seeking a prescription or a workup, the reply of the attending physician quickly tells me what kind of training he went through. If he replies, “Let’s do a full sepsis workup including blood cultures, urine cultures, blood count, and then watch the child to see if we need to do a lumbar puncture or a chest x-ray,” then I know he took the pediatrics route because of his willingness to over order to test while wringing his hands over a possible diagnosis. If on the other hand, the attending wants out of the patient’s room and calls out, “I don’t want to see anyone writing a prescription for this person,” then I know that he doesn’t play around with unnecessary tests and procedures—he went the emergency medicine route.
Since we serve as an urban trauma center, we get to see the worst case scenarios. Because of that claim to fame, I’ve also seen quite a few child abuse cases. A 3-month-old came in suffering a seizure. We ran her through the CT scanner and found that she was bleeding into her brain. We then did an eye exam and saw that she had multiple spots of bleeding in her retina. Apparently, the father had thought that she was crying too much and decided that the best way to calm her down was my shaking her vigorously. He was arrested, and the mother—and who was completely oblivious to the father’s treatment—took over as the sole custodian.
Our peds department comes up with many ideas to improve patient satisfaction, particularly while the family waits. In the emergency department all of our patient rooms are private with a television set in each room. When I walk in the TV’s volume is usually on the highest setting. Whenever I try to ask questions everyone in the family merely gives a “uh-huh” without looking away from Dora the Explorer. I once watched a physician get so frustrated with the nine-year-old’s ability to pay attention that he said, “I’ve seen this episode; Diego makes it,” and then turned off the TV.
Over the past few weeks have been on the pediatrics rotation. I’ve written before that don’t really care for peds as a medical specialty. You see, I dislike working with children. Nothing compares to walking into a child’s room and saying, “Hi, good morning,” and then the kid immediately begins screaming and crying.
There is a stereotype that the field is dominated by women who want nothing more than to play the role of an overeducated babysitter. And while there is some great research that goes into the field, many of the practitioners do fill a bit of those stereotypes. I’ve met quite a few female residents who say they want nothing more than to get married, raise their children as a stay-at-home mom, and then work part time as a pediatrician.
A few days ago, my team needed to meet with our intern before we could check out for the afternoon. We called her to find out where she was, and she replied, “We’re playing with the babies at the nurses station.” I thought she was just kidding. But when we found her, sure enough, every resident and gone into a patient’s room, grabbed a baby, and was found at the nurses station rocking them and playing with them. Now I’m not scared of babies, but I was a little put off when one of my teammates came to me and handed me a six-month-old to hold.
She said, “Talk to him. He needs stimulation.”
“What should I say?”
She replied, “It doesn’t matter. He’s deaf.”
“Then why should I say anything at all? Especially if he can’t hear me?”
“But you never know, he could regain his hearing.”
And now you know what I’ve been working with. My whole team is filled with women who want to go into the specialty. I’m the only one who wants to practice on adults. While most of the kids are fairly benign, I ran across one child earlier this week whose parents had used screaming, profanity, and threats of violence as a way to discipline their child. My assigned three-year-old picked up many of their bad habits. I sat outside his room copying down vital signs when I heard, “Shit shit shit shit.”
I thought to myself, there’s no way he was just saying that.
Then I heard it again: “Shit shit shit shit.”
I walked into his room and introduced myself by saying, “Hi there, Arnold. My name is Half M.D. I’m going to be taking care of you while you’re here in the hospital.”
He replied, “Shut your mouth. I’m going to beat your ass you son of a bitch.”
To the outside observer a cursing three-year-old might seem pretty funny. However, I had to be the one to deal with this mess. I asked the mother where he had learned such words. She said, “Not from me. Sit down, child! I’m going to slap you!”
The kid then raised a royal tantrum and started throwing things. I managed to calm him down for a bit so I could go through the physical exam. I gave him my reflex hammer and told him he was supposed to hit a spot on the bed when I told him to, and then stand absolutely straight after hitting that spot. I found that for many children, letting them play with my reflex hammer and turning it into a game is the best way to calm them down. I’ve also discovered that for children who have a phobia of stethoscopes, if I let them listen to my heart first, they’ll usually let me listen to theirs next.
When the exam was over, I needed to take back my reflex hammer. As expected, he started screaming. I then said, “Goodbye, Arnold. I’ll see you a little bit later.” He responded by spitting at me and saying, “I’m going to beat your ass.” I think that the child is going to be in prison by age 12.
I was growing pretty worried during rounds because I was scheduled to present my case last. I was wondering how I was going to tell everyone, “This is a three-year-old child who presents with cough and fever of two days’ duration. Social history is remarkable for a lot of profanity.” Luckily for me, while we were standing in the hallway outside of a patient’s room, Arnold walked by with his mother saying, “Bitch bitch bitch bitch…” and there went my patient.
When Claire got admitted to the hospital for pneumonia, I knew we were in for quite a long hospital stay. Claire was morbidly obese (her BMI was 51) and although 31-years-old, she had more damage done to her body in the previous three months than most members of the AARP had experienced over their lifetimes.
At my hospital we have a diagnosis known as the “trifecta” in which a patient has hypertension, high cholesterol, and diabetes. Claire had the trifecta. Everyday we tried delicately to manage her sugars; unfortunately, we were losing the battle. Each morning I read off her chart as her blood sugar measurements from the day before were 262, 280, 230, 305. We tried desperately to get her sugars down and threw insulin at her as if it were I.V. saline. Her body was impervious. It was as if the cells in her body were made of Teflon and no insulin could ever penetrate them.
We scratched our heads over her predicament and wonder just how someone can build up a tolerance to insulin. We had her on a no-carb diabetic diet throughout the day and gave her only water and coffee to drink. Finally, on the fourth day of admission, I asked her why her sugars were so high and if she’d been sneaking food. She confided in me that her friends and family visit her at night and bring in cake, cookies, brownies, and anything else they can get their hands on. As she said, “I like to eat.”
We were all greatly annoyed. Here we’ve spent all this effort on trying to manage her diabetes, only to be outdone by a bag of Oreos. Likewise, many patients throughout the hospital are grappling with similar issues of neglect. A lifelong smoker comes in to the clinic to be told that he has lung cancer and then cries out, “How could this be? Was it something that I did? I feel like it’s all my fault.” Naturally, physicians have to put on a professional air around their patients and passionately explained to them that there are many factors which go into causing cancer. In reality, I just want to scream out, “Did you ever bothered to read the side of the box? It says right there it causes cancer.”
I’m constantly amazed by politicians who claim that we need free, universal health care available to everyone in the United States. And somehow, all Americans will instantly become healthy, will give up high fructose corn syrup, and will take up jogging three times a week. Presidential candidates from all political spectrums tout preventative medicine as if it’s some kind of cure to all of the country’s woes. As Claire demonstrated, if people want to eat, they’re going to eat.
I got my evaluations back today for internal medicine. On the whole I did well… except for the eval from my resident. She’s a fresh-off-the-boat foreign medical graduate who doesn’t understand how grade inflation works in the United States. She pulled me aside and said, “You did very well. I gave you a C.” Her comments section was loaded with praise, saying, “Very knowledgeable, works well with the team.” Under the needs to improve section, she had only one word: “unenthusiastic.” She told me, “I know you don’t want to do medicine, but you need to smile more on rounds.”
What!?! Rounds take four hours. I’m not some cheerleader who can come in and say, “Hooray medicine! Goooooo team!” Faking a smile is difficult when my job of pre-rounding is done by 7:00am and the rest of the morning is spent standing in the back of a crowd while my attending opines on starting another anti-hypertensive medication on our patient with the blood pressure of 140/80. Most of my time on rounds is spent fantasizing about having a threesome with my resident—who, might I add, is only minimally attractive at best, yet holds a lot of power over my evaluation.
In medical training we use the Socratic method to teach students. While the method is to find knowledge gaps and fill the holes in a young doctor’s education, the whole ordeal gets to be rather intimidating when the attending is interrupting the student and saying, “What are the components of Ranson’s criteria for pancreatitis?” or “What’s the half-life of labetolol?” Students call this method “pimping” because it’s such a humbling experience to have your ignorance broadcast to the entire team.
In a classic example of pimping this week, my attending wanted to see the differential diagnosis of pancreatitis. I admitted a woman to the hospital with severe upper abdominal pain. My attending asked, “Why don’t you think she’s having pericarditis?”
Me: Because the EKG is not consistent with pericarditis, she has not had any recent illnesses, she has no chest pain, and there isn’t a friction rub heard on physical exam.
Her: That’s right, she doesn’t have pericarditis. I just wanted to make sure that you knew that.
Well she’s not having a stroke, either. Would you like me to tell you why?
The good news is that I put together a patient tracking form to simplify my life on the wards. You’ll notice that I used the medfools card as an inspiration. Their card isn’t very useful for me because (1) it’s two pages and I can’t print double-sided, (2) the cards are too busy and loaded with too many forms I wouldn’t find useful, and (3) the checkboxes take up too much space for a medical student. Only an intern would need to accomplish that many tasks.
In the future, I’m going to make the boxes editable so that users can print out a nicely printed tracking sheet.
As part of the med school admissions process, applicants must write a personal statement in which they confess their undying love for humanity and their willingness to join the medical field for the sole desire to help others. Applicants come up with pretty unique ways of demonstrating their humility with everything from the mundane such as serving lunch to the homeless to extremes such as trips abroad to teach Third Worlders about sanitation and vaccines. When I applied, I had to prove that medicine was my life’s calling. I don’t know why medical schools purposefully force pre-meds to pretend that through divine will they chose medicine as if they were entering the convent and becoming a monk for the rest of their lives.
Part of this humility involves the willingness to treat all people regardless of race, religion, or ability to pay. Although a noble cause, medical schools try to coerce students into this feel-good attitude about treating a variety of patients including criminals, the insane, the criminally insane, and even the stinky. At my own urban hospital, we play host to numerous homeless persons who drop by for everything from getting a drug fix by mentioning vague 10/10 abdominal pain, to those hungry few who couldn’t convince the residents outside to donate a dollar to get a meal—so they show up at the emergency department demanding turkey samiches.
The emergency department serves at a gateway into the rest of the hospital. Its doctors serve as the primary care physicians for a variety of non-tax payers who think that healthcare is free anyway. Our hospital sees drug seekers, samiche seekers, and even skirt chasers. I’ve had quite a few Casanovas call out to nurses, “Hey baby doll, bring me some water and come on over here.” While these pseudo patients with no medical issues are taken through triage, a good physician can stop them there. Unfortunately, a few attendings still believe the personal statement story they wrote many years earlier.
I’ve seen sickle cell patients claim 10/10 diffuse body pain and demand round-the-clock dilaudid, only to fall asleep during the interview because they already had so much morphine on board. For this particular patient, I had to use a sternal rub to wake him up—at which point he slurred his words to say that he was still in 10/10 pain and required more powerful narcotics. I wanted to send him home and tried to plead my case for my attending. My boss said that we could not judge the patient’s level of pain and wrote for a patient-controlled dilaudid pump that would deliver enough drugs every 10 minutes that would send an average man into a coma. This patient was an average man. Nurses found him unresponsive and had to call a code to resuscitate him. When the patient regained consciousness, he stated that he was still experiencing 10/10 pain and requested cinnamon-coated apples for lunch.
Similarly, my current attending wants all patients to remain in-house for complaints that could be handled as an outpatient. I have one gentleman who has been waiting for the results of his biopsy during the past week. Keep in mind that we aren’t actually doing anything for him other than waiting for the test result to come back. When I asked the physician in charge why we’re holding onto the patient for so long, she replied that he may not return to clinic given that he’s homeless. We throw around phrases such as “lost to follow up” to describe patients who miss outpatient appointments. Some of these people are homeless; all of them are uninsured. So instead of losing $400 with the biopsy and clinic visit, the hospital is now losing $10,000 a week just to have the patient sleep in one of our mechanical beds.
The worst patients are the homeless individuals who show up with multiple friends and family members. For the homeless, getting admitted to the hospital is like winning the lottery. They get free meals, a warm bed, and a nurse offers a sponge bath every morning. One patient had six friends show up and demand beds of their own—because in their kindness, they wanted to take care of their buddy.
Instead of charging tax payers the extra expense of hospitalization, let’s send the bill to the attending who hides behind the label of loss to follow up. If nothing more, let’s have med schools cut their nonsense about helping others and admit only students who clearly have a business sense and a wariness to discharge patients when the hospital fails to provide added benefit over outpatient care. Now that’s a personal statement worth reading.
As a medical student, you’ll hear lots of one-line clich‚s that attendings tell to break you into the system. Unfortunately, all of these pearls are lies. Here are just some of the half-truths I’ve run across this year:
“The hierarchy in medicine is just like the military” — Always stated by someone who never served in the armed forces, this lie is meant to justify the way attendings and residents treat students. Apparently, watching the media depiction of boot camp is enough to make physicians tell others, “You’re going to kill someone one day if you don’t pay attention enough,” and other clever insults.
“Pimping is a good way to learn” — Apparently, using the Socratic method is a great way to teach. According to this time-honored tradition, a resident or attending will pommel a student with questions repeatedly until the student finally answers something incorrectly or states, “I don’t know.” Then, the teacher will proceed to humiliate the student further until the day’s lesson is presented. I was once asked during a surgical case about the cause of a woman’s liver adhesions. The attending berated me for having not studied gynecology. Considering that surgery was my first rotation, I don’t know why he would have expected me to know that STD’s cause a sticky liver.
The reason why this statement about pimping is so untrue is that the very purpose of teaching is violated. In order to learn something, you must first be ignorant. If a student shows up to rounds not knowing something, he’s going to get his ass handed to him by the residents. To shine on rounds, the student will instead have to learn on his own and then present that knowledge on the following day’s pimp session. In effect, the teaching session is therefore redundant and not necessary since the student will already know the answers to the question.
Another variation on this statement is “Pimping leads to the knowledge gap.” I have one professor who is fond of telling us that by harassing us with questions, he knows where to pick up the day’s lesson.
“I’ve got an opportunity for you that no one else will receive” — You’ll never get opportunities during third year, only grief. This phrase is meant for attending to force a student into some task that isn’t related to learning medicine at all. My opportunity this week is to sit in on a hospitalist meeting where we discuss patient safety goals and how we can prevent medication errors. My guess would be to have pharmacy techs draw up all of the day’s medications, put them in a plastic bag with the patient’s name and dispense time on the outside, and then drop them off at the nurses’ station. That way, nurses will merely have to pick up Mr. Jones’ 5pm bag of Flomax and bring it directly to his room at the appropriate time. Unfortunately, medical students don’t speak at these meetings, our job is to learn about the process of meetings. Other opportunities that have no bearing on your future abilities as a physician include grand rounds, resident report, and morbidity and mortality conferences.
Feel free to share some of the lies that you’ve heard around the hospital.