I started my obstetrics and gynecology rotation this week. Hence, why I have not been able to post anything in quite a while. The hours are a lot like surgery: I get up around 4:00 a.m. so that I can make it to the hospital by five o’clock. I’m usually there for about 12-14 hours. I then come home completely exhausted, study what I can in what little time I have remaining, and then fall asleep into an almost coma-like state. I worked all seven days this week which, after I get through the next week, I will have put in 13 days in a row. I worked more than 80 hours this week. And while that may seem like a lot, given that my residents were always in the hospital before I arrived and after I left, I am certain that they were putting in close to 90-100 hours.
My previous rotation, family medicine, spoiled me with its relaxed work schedule. I would get up around 8:00—8:30 if I didn’t feel like going in—and then would spend a leisurely eight hours in the office before coming home and chilling out for the rest of the day. Since I had had the bulk of the third-year curriculum prior to starting family medicine, outpatient primary care was a breeze to me. I never bothered studying; in fact, I only spent three days doing a half-assed attempt at practice questions so that I can get ready for the shelf exam. But now that I’m on ob/gyn, everything has changed.
When I woke up at 4:00 a.m. on Tuesday morning, I heard the awful sounds of a siren that for a few seconds I was convinced were coming from outside my window. I figured that an ambulance must be running down my street to bring the latest victim of a shooting to the nearby hospital. When I finally realized that the sound was coming from my own alarm clock, I was greatly annoyed at the misfortune I would have over the next six weeks.
Ob/gyn residents are a lot like surgery residents: they have terrible hours which violate federal work-hour rules, they get greatly annoyed at medical students and have a short temper, and they are so stressed from the work that is constantly dumped upon them by the hospital and the attending that I’m surprised one of them has not brought a gun into the workplace yet and started shooting up the nurses station.
We try to break the monotony in this rotation by allowing students to work shifts in the emergency department, catching gynecological cases. I’ve mentioned before that my hospital serves as an urban walk-in clinic for many of the uninsured people of my city. In the past week, I have seen the 6—SIX!—people come to the emergency department solely to get a pregnancy test. They had no other complaints other than wondering whether or not they were carrying a baby. My resident, my new hero, tried to explain to these women that a trip to the emergency department costs almost $1000 for all of the laboratory work and eventual ultrasound that we would perform. These women, with their glazed over looks, just brushed off the notion that they should ever have to pay for health care. Two of them even became annoyed when my resident suggested that they could go to Walgreen’s and purchase a home pregnancy test for $10. One replied, “I just don’t have enough time in the day to go to the drugstore!” To which my resident replied, “Didn’t you just spend three hours and our waiting room? Driving to the drugstore, purchasing a urine pregnancy test, and then driving home certainly takes a lot less time.” But then again, why should any of these women care? Health care is free after all. Having the latest cell phone is more important than having insurance. And hell, while we’re at it, let’s not bother trying to use birth control to prevent another pregnancy anyway.
Despite working in a private practice family medicine clinic, today I managed to land all of my neighborhood’s psychotic patients who came in seeking primary care.
1. Lady with borderline personality disorder came in asking for a steroid injection into her knee. Her regular doctor was out of town and she demanded that we perform the procedure. As I tried to take her vitals, take a history, and even find out what medications she was on, she kept angrily replying, “All that information should be in my chart! Just give me the shot.” On physical exam, I noticed that she had multiple linear scars on her arms pointing in different directions, a sign that she had been cutting herself for a very long time. She tried to explain the scars by saying, “I have a lot of cats.” We sent her home with a prescription for tramadol and told her she would not be getting a steroid injection from us.
2. Schizophrenic diabetic man came in with peripheral neuropathy of his lower legs. Essentially, that means that his blood sugar has been uncontrolled for such a long time that now the nerves in his legs are severely damaged. The man can barely feel his feet, and what sensation he does have left he describes as constant burning and tingling. He even lost the hair on his legs because his diabetes had gone on for so long. When I asked him how he checks his sugar at home, he replied, “That machine is just too damn complicated to work. I’m so fucking frustrated with how hard it is because I’m a genius. No seriously, I’m a genius.” He then went on to tell me how he had witnessed UFOs and how aliens had been healing his friends of their illnesses. He was wondering when the little men would be paying his home a visit to take care of his illness. We gave him a prescription to Lyrica, which he then forgot on his way out. He never did come back.
3. A couple in their 70s presented for a routine checkup. The man had been diagnosed with OCD previously and had minor anxiety attacks with everything I told him. Since he was about 24 years overdue on getting a colonoscopy, I told him that he would need the procedure to look for any signs of colon cancer. He just about had a heart attack. The wife—who is now on husband number 3—consistently yelled at him to shut up while the doctor was talking. They’re a solid example of marriage as a failed institution.
I surely have lots of respect for you primary care doctors. With the awful payment structure that is bestowed upon generalists, I just don’t see how you guys do this day-in and day-out. Outpatient medicine really is the seventh layer of hell for me. (Layer number six is general surgery.)
As part of the family medicine rotation, all students must prepare a lecture on a selected topic of disease that is commonly seen in the outpatient setting. Our speeches are supposed to be given such that a lay audience can understand material, though we’re really just talking to our classmates. We also have to create pamphlets similar to what is given out in a doctor’s office to sufferers of these pervasive illness is. You’ve probably encountered the trifold pamphlets that have a title along the lines of “Have you had your cholesterol checked recently?” The professionally created note then goes on to list all the dangers of high cholesterol, before finally telling you that you need a particular drug (as prescribed by your doctor of course). These tracts—which look eerily similar to religious pamphlets—are usually created by drug companies as a marketing tool under the guise that they are somehow educating patients.
I have been assigned the topic of vaginitis, inflammation of the vagina that is usually caused by infection. I’ve decided to throw caution to the wind and present a lecture worth giving. I imagine that it would go something like this…
The lights dim, Yanni starts playing, I light a candle and say something classy to the women in the audience like, “You look great. Have you lost weight? I’ve got a talk today that’s just for the ladies.”
(PowerPoint goes to the opening slide)
I’ll then give a definition of vaginitis and describe some of its features: erythema, burning sensation, and discharge. “Red, hot, and juicy? That sounds more like an advertisement for the Steak and Ale than it does a serious disease.”
Next, I’ll have to discuss how women get it. “Most cases of vaginitis are caused by bacteria. Women get infected with bacteria ‘down there’ by committing sin. So remember, preventative medicine is key: go to church and stay away from doctors.”
Finally, I’ll wrap up with the treatment section. To treat vaginitis doctors have to go after the most common causes. Therefore, they typically use metronidazole because it kills most of the organisms that can cause this disease. Treatment decisions are usually empirically based without confirming the presence of the microorganism. Gynecologists are handing out metronidazole like it’s Halloween candy. Like they’re donating Thanksgiving turkeys at the homeless shelter. Like they’re Oprah and giving out freebies. “You get Flagyl! You get Flagyl! You’re all getting Flagyl!”
Now that’s a lecture worth seeing.
I’m sure that many of my readers are wondering how they can be successful once they enter medical school. I thought I’d take the time to tell you some of the habits I picked up which will guarantee your getting AOA and landing the residency of your dreams.
The first step is to hoard all of the information for yourself, and make sure that none of it lands in the hands of your classmates. Common examples include creating an outline for all of the month’s lectures and then refusing to send it to the rest of the class; finding a website that is helpful in clarifying concepts and then neglecting to tell anyone about it; learning that someone else’s patient has had a change in status and then forgetting to tell your classmate so that he’ll be embarrassed on rounds the next day. These techniques may sound rude at first, but remember that your goal is to get your top pick for residency. And remember that all of your class to your competitors.
The second step is to take on extra patients. The higher the patient load, the more the residents and attendings will notice your hard work and will reward you for it. If all of the other medical students are assigned two patients, then you should get a third. You should readily and willingly take additional patients, even if it means pre-rounding on one of your classmates’. Don’t worry, you’ll do a better job of taking care of that person then the other third-years will anyway. That patient is now in better hands.
Finally, you should make sure that you are always visible, even when the resident has already told you to leave twice. When your classmates all agreed to go home after the afternoons lecture, you should very loudly state that you agree with them and that you will promptly leave campus once class is over. The moment everyone else is gone, you should immediately return to the hospital and ask the resident if there is anything else you can do. When the chief inquires as to why you were the only student who has returned, be sure to give some passive-aggressive answer such as, “I don’t know. I just sort of assumed that they got tired of being here.”
Don’t worry about what your classmates say about you. You’ll encounter many people who are jealous of your success. You might even hear sounds of “click click boom,” but you should ignore these. Remember, you’re the one who’s getting to go to the residency of your choice. Everyone else is going to end up in primary care out in the middle of nowhere.
Since you’re a reader of this website, you can print out these tips and keep them in the pocket of your whitecoat. Don’t share it with anyone, ever. In fact, don’t ever tell anyone that you’ve been to this website. Your competition will learn the secrets and may even employ them against you. You need to stay ahead of the game.
(Half M.D.: I wanted to post this on April 1. However, I will be out of town then and am forced to write it now. It’s a joke. Please don’t e-mail me asking if I’ve tried any of these methods.)
This week I’m finishing up my psychiatry rotation. I’m sure I won’t ever have another experience like this where I get to meet patients and physicians who are both so disorganized that I can rarely tell the difference between the two. Before I tell my last story, I just wanted to share with you what one of my attendings said today. As he was filling out my evaluation he noted, “I’m giving you the highest grade I’ve ever given to a student before. You are very talented and I would love to see you go into psychiatry.” He gave me a B+.
Now on to the story:
I had a 30-year-old, 400 pound schizophrenic woman come into the emergency department seeking a medication refill. She is very well known to the hospital as she frequently visits for a variety of complaints. She’s extremely abusive toward staff and has been committed on multiple occasions for violent behavior towards others. She also has a very unique behavior when trying to get the attention of others. The last time she was in the emergency department, the psychiatrist said something to her that she didn’t want to hear. She responded by defecating on the floor. Supposedly, she became so famous after this incident that no one in the psychiatry department wants to deal with her.
When I went to interview her, I wanted to prevent any bad behavior from occurring this time. I decided to talk to her outside. If she was going to pop a squat, at least I could just hose off the sidewalk. For a moment I was tempted to interview her while making her stand in the flower garden. I figure that if life gives you lemons, you should make fertilizer.
She was doing very well with the interview. She was telling me that she no longer heard voices, no one was after her, and her thoughts seem pretty organized. Then I asked her if anyone was jealous of her. She threw up her hand and replied, “They’re all jealous of me!” When I asked her who, she started pointing at every woman outside of the hospital saying, “She’s jealous of me! She’s jealous of me! She’s jealous of me!”
I asked her what she had that these other women wanted. She replied, “They want my SEXY body!”
I refilled her Haldol and sent her on her way.
Whenever a patient visits the doctor’s office, there is always an idealized hope that the patient and physician will work together to come up with a treatment plan. Part of the management of disease involves making sure the patient understands the risks and benefits of a particular therapy. In order to do so, patients must have capacity to understand what treatment entails. The patient may refuse any treatment for any reason, so long as he has the capacity to understand what the risks are when refusing treatment. For example, a Jehovah’s Witness could refuse to take a blood transfusion even when his anemia is so bad that he could die from poor oxygen perfusion. Similarly, any adult can fill out a Do Not Resuscitate order with the understanding that if he should have a heart attack and suffer cardiac arrest, no one will come to his aid.
In psychiatry, however, many of our patients lack capacity. One might be so psychotic that he does not understand his negligence may cause harm to himself or others. Psychiatrists are constantly asked to determine a patient’s ability to understand treatment decisions. Sometimes, a person might be forcefully admitted to a hospital for treatment if his mind is so disorganized as to cause immediate, life-endangering health problems. Psychiatrists can hold a patient in a hospital for a given number of days to provide treatment for medical or psychiatric illness. During this time period the patient has the right to legal representation and may petition a court seeking discharge from the hospital.
Today, I got to sit in on a court hearing for a patient to was so psychotic that he did not notice that the cellulitis on his legs had become necrotic. In my state, the district attorney’s office serves as the hospital’s legal representative to keep the patient involuntarily committed for treatment. The public defender’s office represents the patient. Our attending began giving a summary of the patient’s hospital stay over the previous week. He mentioned that the patient has been washing his face in the toilet, shouting racial slurs, making sexually inappropriate comments about nurses, and talking about the fourth Reich. At this point the patient then began doing the Nazi salute and stated, “Black people are dangerous.” When the defense attorney began questioning the patient, the conversation with something like this:
Attorney: I understand that you are a veteran. Are you willing to take treatment at the VA?
Patient: They are all robots there. I would kill every one of them.
Attorney: Do you want to stay here in the hospital? And if so, how long?
Patient: I want to stay here for 60 years.
Attorney: Do you understand that you are sitting in front of a judge and have the chance to be discharged from the hospital? Now I’m going to ask you again, how long do you want to stay in this hospital?
Patient: 60 years!
Attorney: What do you plan to do once you’re discharged from the hospital?
Patient: I want to go to the South hospital for six years.
I was pretty sure that our side was going to win the verdict when the judge began laughing.
Nothing’s scarier in a psychiatric hospital than seeing a patient who was brought in by police officers with his hands handcuffed behind his back. My hospital has a separate psychiatric emergency department that is located away from the rest of the hospital. For whatever reason, please officers often arrest violent individuals and then bring them in for us to deal with. Usually, I’m pretty confident interviewing one of our attempted murderer guests when they’ve been drugged up on Ativan and tied to a bed. Last week police officers Baker Acted a 250-pound antisocial gentleman who was stopping Hispanics and violently demanding that they show him their papers. The officers brought the man to the psychiatric hospital, took off the handcuffs, and left him alone to be interviewed by me.
I went through the regular interview and noticed that the patient was becoming more and more agitated. In these situations, we are supposed to immediately end the interview and leave the room. When I was trying to walk out on this particular patient, he decided to charge after me. I quickly tried to close the door lock the patient in this room, be forced the door opened before I could get my key into the slot. He tried to take one swing at me, but by that time a police officer who just happened to be walking through the hall pulled out his Taser and yelled, “If you take one more step forward I’m going to shoot you!” The patient backed down, the nurses restrained him, and we gave him a nice shot of Haldol and Ativan to chemically control him.
I had hoped that the hospital had learned a lesson about restraining patients before interviewing them. You can imagine my surprise then, when my last patient of the day produced as his only form of identification a card that read “Corrections Inmate.”
Instead of giving you, my readers, another diatribe about the world of psychiatry, I’ve decided to use this holiday to do something different. During clerkship lectures I get so bored that I usually spend the hour surfing the web on my palm pilot. Unfortunately, the mental health building at my hospital does not get WiFi. Therefore, I’m stuck trying to find other ways to keep myself entertained/sane. I’ve taken to writing poetry and making little drawings on note cards. I want to post some of the haikus that I’ve been writing.
Do you know the day, month, year?
Can you draw this shape?
Real patients, fake physicians.
Why wear the white coat?
The shrink’s battle cry:
Here’s a script to Wellbutrin.
Take it with water.
Recently I wrote about my disdain for psychiatrists who wear white coats. In no other field of medicine will you see such a shiny, immaculate white coat as those worn by psychiatrists. Many of the residents I know have coats with creases in them that are as sharp as the day they bought them. To this day, I’ve only seen one psychiatrist with the stain at any time on his white coat. He openly admits that the discoloration is to due some coffee spilled during break.
Psychiatrists run in fear from any medical issue that patients may present with. Slightly elevated blood pressure? Call an internist. Slightly elevated blood sugar? Call the internist. Slightly elevated cholesterol? You get the idea. The residents and attendings use a shotgun approach to ordering labs and when anything comes back abnormal, they run and hide behind other doctors like a terrified small child does when he hides behind his parents’ legs. Now I know they had to learn medicine during medical school. I know they had to pass STEP III to get licensed as physicians. But the overwhelming response from psychiatrists—when presented with medical issues—is, “Why concern ourselves with kidney function and other nonsense when there are other pressing issues at hand?” On two separate occasions I have witnessed residents state that metformin leads to hypoglycemia. Any first-year medical student knows that metformin, a drug used to manage diabetes, is employed as a first-line treatment precisely because it does not cause hypoglycemia. Yet here they are, these disgraces to the title M.D., making untrue statements about the side effects of a very popular medication.
Psychiatrists act as if they should not concern themselves with medical issues, yet then get offended when people say that they aren’t real doctors. In this rotation we employ a device known as the mental status exam (MSE) to check our patients’ functional abilities. I have heard more than one practitioner state that the MSE is the psychiatrist’s physical exam. To this day I have yet to see a note that links the MSE to the body in a similar fashion that a neurology note can link physical exam findings to lesions in the brain. They claim to be medical experts of the mind, yet are neither talented as physicians nor as therapists. I cannot think of a greater waste of education than that of psychiatry.
For every psychiatrist there is, one seat in medical school is given up so that a person can join the pseudoscience realm of Freud. Their expertise requires eight years of training (four years of medical school + four years of residency) that do not translate into meaningful results. At best, they are misunderstood practitioners of the id and super ego. At worst, they are directly leading to the current shortage of medical doctors.
Therapists, on the other hand, make a unique contribution to the world by promoting insight and new behaviors that can lead to a decline in depression, anxiety, substance abuse, and maladaptive work and social behaviors. Therapists require many years of training and experience to provide an unparalleled level of service to people who need them. I have no problem with therapists. Psychiatrists, however, are a drain to our society because they can neither serve as medical physicians nor are they skilled practitioners of psychotherapy. Our only hope is that Medicare and insurance companies continue to cut reimbursement rates for psychiatrists to the point that the field is abandoned altogether. Only then will be free of their tyranny.
In most areas of medicine, you will encounter fairly mundane diagnoses carried by ordinary people. For example, a primary care physician might see 30 patients in one day, 25 of whom came in for cholesterol checks, blood pressure checks, or sugar checks. In psychiatry, however, each day brings with it a chance to meet the nation’s greatest citizens. Just this past week I met the inventor of the Knight Rider car, three millionaires, and a four-star general in the Air Force who ensured me that his commitment to the hospital was a mistake and that everything would be okay if I would just contact the Pentagon for him.
While documentation is important in any medical field, I have learned the art of buffing a chart on this rotation. On every other clerkship we students diligently note all of the patient’s complaints, their disease history, and all the findings on the physical exam. We do not bend any of the patient’s information, nor do we editorialize to make the patients seem sicker or healthier than what is presented to us. On this rotation, for whatever reason, we try to make the patients seem as ill as possible. “Buffing” is the act of adding information to a chart that was not stated by the patient, not found in the physical exam, or simply untrue for the sole purpose of trying to sway the reader in a particular direction. An example in emergency medicine might be a patient who comes in with a complaint of shortness of breath. To get the person examined by a cardiologist, you might also say that the patient has chest pain once an abnormal EKG is discovered. Buffing is highly illegal but is practiced by many physicians to varying extremes.
In psychiatry we make buffing seem like it’s a perfectly acceptable part of medicine. On any given morning I might round on a patient who tells me that he no longer hears voices and has no thoughts of hurting himself or others. He might further state that he wishes to be discharged so that he can go back home and live his life. The nurse’s report might state that the patient has been perfectly cooperative throughout the previous day, that he has mostly kept to himself, and that he slept throughout the night without any intervention or extra medication given by the nursing staff. In a chart I will then state that the patient continues to respond to internal stimuli (meaning that he’s hearing voices), that he is isolated and withdrawn, and that he needs continuous 24-hour monitoring to ensure that he is not a danger to himself or others. This practice of buffing the charts is not only encouraged—but required—by my attending.
I doubt that we will ever be caught because the laws protecting mental health charts are different than those for dealing with medical charts. In regular medicine, a patient has access to all of the information in his chart. If you want to see what your doctor has been writing about you, simply call his office and ask that your chart be photocopied and delivered to you. Mental health notes, on the other hand, cannot be revealed to a patient due to the sensitive nature of what they contain. Therefore, we already have one of layer protection separating our buffed notes from the patient’s inquisitive eyes. Further, if a court order should ever force us to turn over our notes, a patient is going to have a hard time arguing against a physician that he was “responding to internal stimuli.” We’ve done such an amazing job of painting all of our patients as psychotic, antisocial murderers that I’m sure we could charge admission fees to lectures on how to buff a chart. As my attending admitted, “Anyone could qualify to be a patient here.”