Medical School 2020, Year 3, Week 24 (Internal Medicine, Week 6)

Last week before exams and our first break for the year. Sleek Sylvester, Ditzy Diane, and I are worn out, our motivation waning. We have a new team of residents for the last three days and none of us have the desire to impress them. The senior resident: “Let us know if you have any questions. You guys can just study if you want. We’ll let you know if anything exciting is happening.”

We are actually helpful on Monday during rounds, having previously admitted many of the patients on our service. We provided the only continuity of care for these patients and were tasked with presenting a formal H&P for each of our three patients to the new team.

We also play “Stump the Med Student” on rounds. A 36-year-old gas station clerk, whom I admitted three days ago, has acute renal failure from multifactorial causes — hypertension, uncontrolled diabetes, and three-month long ibuprofen use. He stopped taking his diabetes and blood pressure medications five years ago. The senior resident asks, “Why is his sugar low and his Hemoglobin A1C in the normal range if he is an uncontrolled diabetic?” Sleek Sylvester, Ditzy Diane, and I put our heads together and come up with nothing. “Insulin is cleared by the kidneys,” explains the senior resident. “If you see a patient whose diabetes suddenly becomes remarkably well-controlled after years of noncompliance, it’s likely a result of his kidneys failing, not that he has seen the light and has started to listen to your every piece of advice. It’s ironically the first sign of a serious complication. Our patient likely will be on dialysis for the rest of his life. I don’t think his kidneys will recover.” He concludes: “Well, I’ve done my job for the week; go study.” 

After rounds, we do UWorld questions in the lounge, disrupting the residents who are trying to get their notes into Epic. We relocate to the cafeteria for lunch and find Geezer George and Mischievous Mary. Geezer George is doing his elective orthopaedic rotation. “I’m determined to do ortho. I am ready to be miserable through the application process.” Are you concerned about getting into a residency program? “Yes, but my mentality is if the average step score is 245 for ortho, and I know people with 260 are being accepted, that also means they must be letting people in with 220.” Sleek Sylvester questions his symmetric Bell Curve assumption: “Why stop there. People get in with 270, that means they are letting people in who barely passed!”

Jane has had a slow end to her Ob/Gyn rotation with no surgeries scheduled for Monday. She did, however, enjoy M&M (morbidity and mortality) conference. “The attending was pimping the residents. I was like, Bitch, don’t stop! The residents were squirming, it was great.”

I arrive for the three-hour 8:30 am NBME clerkship exam on Thursday at 8:00 am. Type-A Anita and Southern Steve just finished their radiology rotation. They struggled to stay awake in the dark reading room while getting pimped by the radiologists. “The radiologist would put up a study, and select one of us to give an impression on what is wrong. We would utterly fail most of the time.” Steve: “Do you remember that one abdominal CT? We kept focusing on what we were convinced was a hernia. Turned out to be just a normal penis… Apparently there was small bowel thickening from gastroenteritis.” Anita: “Boy, did he get a laugh out of that.”

Internal Medicine exam questions focused on adverse effects to medications (e.g., Stevens-Johnson syndrome in anti-epilepsy medications), management of acute coronary syndrome, and several rare autoimmune disorders.

On Friday starting at 9:00 am, I had two 15-minute encounters with standardized patients, each followed by a 10-minute write-up. One patient was suffering from new-onset chest pain patient while the other had worsening shortness of breath from CHF versus COPD. We are alone with the “patients” while a video recording is made. Our grade is based on a review from the standardized patient (“Did the medical student empathize with my situation?”; “Did the medical student cover me appropriately during the physical exam?”; “Was the medical student’s interview organized?”), a review of the video by a physician or another standardized patient, and the quality of the write-up, again reviewed by a physician or another standardized patient. This prepares us for the pass/fail fourth-year Step 2 Clinical Skills (CS) exam (good news: 98 percent pass rate; bad news: the all-day test costs $1,290 plus travel expenses to a designated testing location, e.g., Los Angeles, Houston, Chicago, Atlanta, or Philadelphia).

Statistics for the week… Study: 8 hours. Sleep: 5 hours/night; Fun for me and Jane: visit her sister and one-month-old nephew. Not fun for Jane’s sister: We practiced testing the baby’s primitive reflexes.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Medical School 2020, Year 3, Week 23

Week 5 of internal medicine clerkship. During Monday morning rounds, Formal Frank asks, “Bianca, why do you keep giving Diane the vegetables? Our goal is for medical students to get practice talking to patients.” Diane’s first patient was a patient with primary aphasia, then a patient with dementia that had progressed to aphasia. She once again has taken an overnight admission who cannot speak but a few words due to Lewy Body dementia.

I admit an 85-year-old patient with acute mental status changes brought to the ED after a “fall from standing”. He is accompanied by two women: 40 and 45 years old. It turns out that the 40-year-old is the wife of five years while the 45-year-old is the daughter. The wife is the one who knows everything about his care, answering all of our questions with a heavy Vietnamese accent. Boss Bianca and I check on our patient around 7:00 pm. He was lethargic, but oriented to person, time, and place. After the wife and daughter step out, he calmly said, “I know I am not going to make it to my granddaughter’s wedding.”

I arrive Tuesday at 6:00 am to learn that our patient died overnight, perhaps due to undifferentiated sepsis. The family declined an autopsy. The night team reports he went in and out of ventricular fibrillation twice over a 30-minute code. “We even gave him a bicarb bolus [last resort in severe metabolic and respiratory acidosis]. The family was present and they understand.” This was the first patient death for Tiffany and Bianca. Bianca took it pretty hard: “That’s crazy, we talked to him a few hours before this happened. Isn’t that surreal how he almost knew?”

The residents have their weekly “didactics” seminar this afternoon, so they let us go after we finish our notes at 2:00 pm. Sylvester, Diane and I grab burritos. Sylvester describes his experience on surgery. “We had a patient with Fournier’s gangrene [necrotizing fasciitis of the scrotum]. We performed a scrotectomy [removal of scrotum] leaving his balls hanging exposed with just gauze covering them. As soon as we cut into the scrotum, gas was released, no pus. The entire OR staff gag from the smell at the OR entrance tunnel with the door closed. ” He had a more enjoyable trauma rotation. He describes a stab wound causing a “shish kabobing” of multiple small bowel loops at different sites, and a hemothorax.

Diane, settling on pediatrics after her experience on IM: “I can’t deal with adults. They are just like babies, except they never grow up.” Both Sylvester and I are interested in internal medicine, though I say, “hospitalists sometimes seem like micromanagers with specialists doing the interventions. Sometimes all we do is give the patient IV fluids and send them home.”

With only one week left before exams, everyone is trying to cram in the 25 LCME-mandated online cases. A typical case starts with six photos, one of which is relevant to the medical questions. The other five depict a non-white-male physician and a non-white-male medical student talking to a patient, e.g., an elderly white man suffering from COPD. There are 10 questions (3 short answer, e.g., summarize relevant history and exam findings) embedded in 5 pages of text. Diane says that she is finished with the questions and actually found them valuable. Everyone else clicks randomly through the multiple-choice questions and responds with gibberish to the short answer questions. Due to rumors that some clerkship coordinators look through the student report, including the time spent on each case, Gigolo Giorgio opens four cases in four separate browser windows in order to build more clock time per case. Sylvester has copied this strategy.

Wednesday after rounds, Bianca takes me to remove a jugular vein hemodialysis catheter on a patient with dementia who cannot speak or react to speech. We discuss the steps while walking up the stairs. First, place the patient in Trendelenburg position (feet elevated above head). Why? Bianca: “Air bubbles travel up, we don’t want to send an air embolism to the brain.” Second, pull the catheter out on an exhalation when there is more intrathoracic pressure. If patient is awake, ask him or her to hum. Third, apply pressure to the site for three to five minutes if the patient has no coagulopathy (change in normal coagulation function, e.g., from warfarin or heparin anticoagulation). Apply Tegaderm and a folded “4×4” (standard gauze) for air seal. The patient survives my first removal of this type of catheter!

Nearly all of our patients have congestive heart failure listed in the Epic chart, but their last echo often shows only  “grade I diastolic dysfunction,” not clinically significant. During initial interviews, patients are confused when I ask how their heart failure is controlled. They’d never heard about this diagnosis. Boss Bianca, “Don’t take things the notes and problem list in Epic at face value. Just in our time here I’ve submitted five safety reports for medicine issues. Transitional cell cancer, are you sure…? Look at the original doctor note [frequently a scanned image from an outside institution, available under the Media tab]; don’t play Telephone.” She continues, “At my medical school, a patient was labeled for three years as HIV-positive. The patient only found out this was in his chart when he requested his medical record after moving to a new city. It turned out a nurse originally meant to put HCV [hepatitis C virus] in the past medical history, and the physician just signed off on it. Let’s just say the patient won a lot of money.”

(Hospitals have a financial incentive to mark patients as having congestive heart failure and other serious conditions because they are entitled to get paid for more of their readmissions if they are treating a sicker population.)

Friday morning report. A senior resident goes over a recent case of tuberculosis (TB): “An 35-year-old undocumented immigrant presents for several weeks of hemoptysis [coughing up blood] and generalized malaise. She had seen by two urgent care providers who prescribed antibiotics. What risk factors did our system miss?” She answers her own question: “Well, first she is an immigrant with barriers to healthcare access. Her boyfriend recently was in prison. We also learned that she was smoking cigarettes picked up off the ground.” She describes the challenge of caring for this patient because she kept wanting to leave the hospital. “She did not understand the contagiousness of TB. She left AMA [against medical advice], exposing her family [5 kids from 3 fathers] to TB. She frequently would get out of bed and walk around the halls despite pleading from the nursing staff. The boyfriend and cousins would visit, but, despite the provision of Spanish language interpreters, could not be made to understand the need to wear specialized N95 masks when visiting her in the negative pressure isolation room.”

One nurse contracted TB and five more had to go on long-term isoniazid treatment for tuberculosis prophylaxis. The senior resident concludes: “Efforts to reduce TB have been so successful that we forget about TB in our immigrant communities.” The trend is toward U.S. physicians seeing patients with more advanced TB, 18 percent of cases in 1995 and 24 percent in 2006.

[Editor: If the boyfriend was in prison, shouldn’t that have made it easier for her to access health care? One fewer household member to take care of.]

Diane admits a 55-year-old for alcohol withdrawal. His BAC is 0.35 g/dL (blood alcohol content; the legal limit for driving is 0.08). Bianca orders a measured osmolality test, mostly for student benefit. We sit down in the resident lounge to go over the results, which show an elevated osmolality gap (“Osm gap”). “Most osmoles are captured by a CMP [complete metabolic panel] — those are sodium, glucose, and BUN [blood urea nitrogen]. Not many compounds can significantly alter the osmolality of blood, except your solvents: ethanol, methanol, ethyl glycol. So we can calculate the osmolality from a CMP. Whenever you see a severe metabolic acidosis, consider getting a measured osmolar and compare to the CMP-calculated osmoles.” Bianca sends a group iMessage: “Why is this called a teaching hospital? Because we do a lot of tests.” Regarding the concern that our edification was driving up costs for patients, Bianca responded “He’s on Medicaid so he won’t pay anything.”

Last day of Formal Frank. I appreciated his high standards and his professionalism with patients. Further, he engrained the need to not forget basic physical exam skills in the work up of patients. Every patient with a GI bleed gets orthostatics. Every chest pain patient gets bilateral blood pressures to rule out aortic dissection. These are simple low-cost tricks that can significantly change patient care. He had a good understanding of cost and benefits. For example, he mentioned that “we spend about $100,000 for every folate deficiency diagnosis. So rare if the patient is eating any kind of food.” [he still allows residents to order folate work up.] I hope to use the Osler test to prevent the misdiagnosis of hypertension in the elderly when I do my outpatient family medicine clerkship.

Pinterest Penelope promotes a school-run LGBTQ awareness event: “Just because someone ‘doesn’t know’ if a person is trans, does not give them a free pass when they misgender that person.”

Shortly after reading this Facebook post, I had my first encounter with a trans patient. He presented to ED for alcohol detox and, after determining that he had no other medical issues, we transferred him to the inpatient psychiatric unit, which handles all uncomplicated detox cases. He is listed as female in Epic, which shows multiple similar detox visits, one each of which he received a pregnancy test. Formal Frank: “They want to change their sex to their identified gender, but if they succeed insurance will frequently not pay for the appropriate screening tests. Our Epic department has spent a lot of time developing an item for gender and a pop up message to alert the provider about the correct gender. We’ll let psych deal with that.”

Statistics for the week… Study: 10 hours. Sleep: 5 hours/night; Fun: 1 night. Saturday afternoon guitar jam session with Gentle Greg to practice for upcoming coffeehouse medical school open-mic night. He’s going through a difficult time with his girlfriend of three months. They’re both Indian-Americans. He’s studying to be a doctor and she is studying to become a physician assistant. However, her family is Hindu while his is Muslim. She is concerned that her family won’t accept him, despite the fact that he is not observant. (They will later break up and then reunite after she talks to cousins who’ve successfully navigated initial family disapproval.)

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Medical School 2020, Year 3, Week 22

Week 4 of Internal Medicine clerkship, same team. Monday is call day. Our team is responsible for divvying up admissions to the hospitalist service. Our team has a low census (only about 6) after all the discharges so we’ll admit 6 patients today. I take the first admission. A 93-year-old female with Alzheimer’s and vascular dementia and COPD (chronic obstructive pulmonary disease) presenting via EMS (ambulance from the nursing home) for worsening shortness of breath. Typically, the medical student is tasked scouring through the 40-page stack of medical records sent from the nursing home for prescription medications. Fortunately, her three children, one granddaughter, and a great granddaughter are present to give a full history of her health. Her daughter: “She never smoked a cigarette in her life.She got COPD from second-hand smoke; her husband was the chain smoker.” Tiffany: “Now you see the challenge with the elderly. If they don’t live near family, it can be a crisis. Her past medical history is an enigma. We don’t know her goals of care, or if she already has a living will.” 

Her wheezing is audible from the hallway, but she is oxygenating well on 2 liters NC (2 liters oxygen delivered via nasal cannula prongs). We step out into the hall and explain her GOLD Stage 4 COPD (most severe) to her family members. She arrived in actual (as opposed to coding gimmick) respiratory failure. She has a severe acute respiratory acidosis with chronic metabolic compensation shown by ABG (arterial blood gas sampling). We avoid intubation by giving back-to-back DuoNeb nebulizer treatments until IV methylprednisolone (steroid, similar to cortisol) kicks in (about 30 minutes). We order a BiPAP (bilevel positive airway pressure) machine from the resident lounge. Briana emphasizes as we wait for the elevator, “BIPAP is never used unless there is a foreseeable improvement from a specific intervention — when in doubt, intubate. It is the safest intervention.”

We head up to the resident lounge to type H&P into Epic. Two hours later, we meet the attending, Formal Frank, in the ED to present our admissions. Sylvester describes a newly diagnosed lung cancer patient. Diane presents an undifferentiated pericardial effusion (fluid around the heart). In the room with my patient, the attending notes her inability to speak more than two words and that she is using accessory muscles (e.g., between ribs or in the neck) to breathe.

Formal Frank asks the granddaughter, “What is her baseline?” A great-granddaughter responds, “This isn’t her, she’s a stubborn old bat, but she’s as sharp as a whip. She remembers small details from our childhood. Right now she doesn’t even know who I am.” 

Formal Frank asks us, “You ordered BIPAP, but is she using BIPAP?” We stare at each other. “Just because you put something in the computer doesn’t mean it happens. Nurses think of our orders more like recommendations.” He had guessed right. Due to a combination of our patient improving and her dementia, the respiratory therapist had apparently given up after setting up the ($2000 billed to Medicare) machine. 

As far as I could tell, the 45-year-old granddaughter stayed in the room for the entire five-night stay. She worked from her laptop and phone and slept in the recliner chair. Every time a nurse came in, she would ask what the next step would be. She related her concerns about the nursing home. “Her medications are ordered PRN [as needed]. That becomes an excuse for them not to give them,” says the granddaughter. “Their nurses are lazy, not like the ones you have here.” I work with the granddaughter on an updated list of medications, including an inhaled steroid for the GOLD stage 4 COPD.

My next admission is a 22-year-old patient with two-day history chest pain. A CT angiogram performed in the ED showed a pulmonary embolism. She also has numerous skin lesions. She has clear moon facies (swollen “moon face”) from steroids used for immune system suppression since age 9, when she received her first kidney transplant.

We get a deeper medical history from the mother, although she did not know the cause of the initial kidney failure. Either the kidney biopsy that would be standard today was never done or the mom can’t remember the result (or was never told). After all of the billions of dollars spent on electronic medical records, we’re forced to rely on the memory of laypeople for a continuous history of anyone who has been seen at multiple institutions.

We restart the patient’s immunosuppressive medications and start her on a heparin infusion for therapeutic anticoagulation.

I present the patient bedside to Formal Frank and Boss Bianca. The patient doesn’t have any questions, and we go into the hall to discuss. Formal Frank: “This is an exciting case! Think of everything this could be. What could cause a PE?” Sylvester, Diane, and I can’t come up with anything other than a run-of-the-mill PE from a DVT. Bianca: “Dig Deeper! People on immunosuppression are at a 100 times risk of developing cancer. She could have a nephrotic syndrome that causes you to be hypercoagulable. People with kidney transplants are at increased risk of glomerulonephritis. She’s also on a fibrate, maybe she has a heart attack.” (We don’t get to explore these issues, unfortunately. The patient’s shortness of breath resolves and she is discharged after two days to resume her job at Subway and see her outpatient specialists.)

On Thursday, Boss Bianca corrals the three of us after rounds. We head to the supply room, tucked away in the labyrinthine basement, to get several punch biopsies. “I have a surprise for you.” A patient admitted overnight to a different team may have syphilis. The 26-year-old relapsed on meth two weeks ago after his girlfriend left him. He has had several ulcers, largest in diameter about 4 cm and 1 cm deep, pop up on his body, including on his forehead, elbow, wrist, and back. “Look at me. I can’t go to work or anything.” We each choose a location and perform a punch biopsy. Later, I checked his chart and the syphilis tests came back negative. A dermatology consult did not result in a definitive diagnosis, but noted the possibility of an immune reaction to meth, possibly a necrotizing vasculitis?.

[Editor: Parents of couch-bound Xbox-playing youth nationwide should use this guy as an example. Even a meth head had a girlfriend and was passionate about going to work.]

Bianca and I run upstairs for a code blue for a 80-year-old DNR (“Do Not Resuscitate”) who is scheduled for transcatheter aortic valve replacement on Friday. He went asystole (flatline EKG). Boss Bianca instructs a nurse to get basic labs, a 12-lead EKG, and to get her the family’s phone number. “DNR does not mean do nothing. Check glucose, hypoxia, treatment arrhythmias.” She taps my shoulder to look at his Cheyne-Stokes breathing pattern. He would take 4-5 deep breaths, then stop breathing for several seconds. Bianca speaks to the daughter and explains the situation that he is DNR, and therefore no further interventions are indicated. The family understands, and says that they knew this was likely and that the valve replacement was extremely risky. Bianca instructs Tiffany to call the surgeon and tell her that the patient is dead.

[Editor: Medicare would have paid over $60,000 for the valve replacement, had the patient survived long enough to receive it.]

Friday is the medical students’ “24-hour” shift, from 6:00 am until morning rounds on Saturday (i.e., about 9:00 am). We work with our normal day team with rounds, followed by notes in the resident lounge. We attend a few procedures on our patients, e.g., endoscopy for GI bleeds, and then join the night team at 6:00 pm.

The chief resident functions essentially as an attending. She was asked to stay for an additional “chief” year following PGY3. She and I head to the med/surg floor to perform paracentesis (“tapping the belly”) on two patients with alcoholic cirrhosis.

[Editor: The good news that I learned at Harvard Medical School in 2019 is that these patients are not “alcoholics.” At worst, they are suffering from “alcohol use disorder.”]

I use an ultrasound to locate a pocket of fluid on a 35-year-old alcoholic cirrhosis patient with a belly swollen from ascites. She is animated, intelligent, and sober following two days of detox. It is tough to imagine that she is on disability and suffering from end-stage liver disease. I locate a pocket that is clear of bowel and mark it with a pen. My chief then preps and taps the belly. We get 4 liters, four test tubes of which we send to the lab for albumin ascites gradient (SAAG) to determine if there is portal hypertension or an inflammatory process. 

The chief lets me do the next one, on a 65-year-old former alcoholic. After sticking a needle into the belly, advancing the catheter, and retracting the needle. The patient feels better after 2 liters, but we keep going until we’ve extracted 10(!). We increase his IV fluids to compensate for the expected dehydration.

We are beginning to fade at 1:30 am, fighting over who will get stuck with the next patient rather than who will get the privilege of taking the next one. The chief sends us home at 3:00 am. Sylvester and Diane both sleep at the hospital in the medical student call room. I decide to go home for 2 hours before returning for Saturday morning rounds at 7:00 am. I finished my notes before heading home so I leave after rounds and sleep.

We get the rest of the weekend off. 

Jane had an exciting week on inpatient gynecology. A 65-year-old patient presented with stage 4 cervical cancer and necrotic tissue in the vagina. She’d been having regular checkups with a nurse-practitioner who ordered labs and assumed that the patient was seeing a Ob-Gyn and getting standard-of-care Pap smears. The doctors were outraged that this had been missed and now this otherwise healthy patient was sentenced to death.

[Editor: Although this patient plainly would have benefitted from screening tests, there is debate about whether the U.S. standard of care is the right one. See “Harms Of Cervical Cancer Screening In The United States And The Netherlands” (Habbema, et al. International Journal of Cancer 2017, 140:5): “Our main finding is that harms occur much more frequently in US than in NL, while the levels of incidence and mortality have been quite comparable between the two countries…” (the Netherlands screens at only about half the rate of the U.S. and only for women 31-60)]

Jane is exhausted and sore when she returns home. She spent five hours total driving the uterus with a uterine manipulator. “I was pushing so hard, my feet were slipping, but they kept saying, ‘Harder. Harder. Lift the uterus.’ Afterwards my hands were shaking. I could barely squeeze.” She continued, “And of course they then asked me to suture. They thought I was really nervous, but actually I was having trouble gripping the instruments.”

Statistics for the week… Study: 6 hours. Sleep: 5 hours/night; Fun: none.

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Medical School 2020, Year 3, Week 21

Monday morning, Terrific Tiffany and I admit a 59-year-old HIV-positive patient (my first) with coronary artery disease for a pre-syncopal (nearly fainting) episode and chest pain. His Hepatitis C and liver cirrhosis suggest a history of drug use. He presented because of the chest pain and running out of his nitroglycerin sublingual tablets. During the interview, he also reports a two-month history of black tarry stools. Fecal occult stool test is positive, his hemoglobin is 6.4 (normal: 13.5-15; worry: 9; transfuse: 7). Tiffany allows me to put in the basic orders for practice: 2 prbc (packed red blood cells), H&H (hematocrit and hemoglobin tests) q6h (every 6 hours), gastrointestinal consult, cardiology consult, troponin q6h, normal saline at 1.5x maintenance, protonix 40 mg iv q12h, and 2 large bore IVs.

If he is not having an acute GI bleed, his hemoglobin should increase approximately 1 Hg for every 300 mL prbc bag. Six hours later, his hemoglobin result is 8 Hg and his chest pain has resolved.

Diane, Sylvester, and I join for the afternoon Esophagogastroduodenoscopy (EGD) study in the endoscopy (“endo”) suite. Under supervision from a GI attending, the GI fellow makes the scope do a U-turn to look backwards at the stomach. He points out GAVE (gastric antral vascular ectasia; dilated blood vessels in the stomach antrum leading to a “watermelon appearance”). We find three arteriovenous malformations (AVMs, dense collection of friable vessels) in the duodenum. “GI attendings love to pimp on this,” notes the fellow. The attending requests a pediatric colonoscopy scope to go further into the small intestine to investigate the jejunum (middle part of the small intestine, typically found empty in autopsies and therefore derived from the Latin for “fasting”). The fellow struggles to advance the longer endoscope, so the attending takes over and explores another 3 feet of bowel.

We find 2 more AVMs, none bleeding. The endoscope has a sprayer for liquid nitrogen and they use this to freeze off the AVMs. Each of us is then allowed to practice driving the scope from the stomach through the pylorus. Sylvester: “Just like a video game.” Afterwards, I ask the GI attending, “Do you really think AVMs were the cause? Can he do anything so this doesn’t happen again.” GI attending: “We do not know what causes AVMs, but there is a clear relationship with aortic stenosis [AS]. If you cure the aortic valve stenosis, the AVMs go away! He doesn’t have significant AS, so he just has to live with them. He’ll have to come in every few months and get a transfusion. More importantly, his multiple comorbidities would not make him a good candidate for aortic valve replacement.” 

During lunch, Boss Bianca goes over the REDUCE (Reduction in the Use of Corticosteroids in Exacerbated COPD; chronic obstructive pulmonary disease, typically from smoking) trial with us. Sylvester and I had prepared by reading up on the REDUCE trial… for prostate cancer. Our discussion was delayed 15 minutes so that we could read the correct “REDUCE” study.

REDUCE investigated whether steroid use could be reduced from the standard of care 14-day course of 40 mg of prednisone to a 5-day course without worsening the estimated 33 percent re-exacerbation rate within 180 days of index hospital discharge. Bianca explains, “Before this trial, you would get 20 different answers about duration and indication of steroid use for patients from 20 different doctors. This was a pivotal trial because it allowed evidence to treat quick-responding patients for only 5 days, but you have to treat the patient until they improve. If they are not improving on day 3, by God, you are not going to stop giving them in two days.”

Sylvester, who struggled in our statistics course, tries to impress Bianca. “I am just a sucker for statistics. I loved how they took the stance of the two groups assessing if they were ‘noninferior’ by using hazard ratios.” Bianca stares blankly and continues, “How might our patient population differ from the study population in Switzerland?” Diane brought up one difference: everyone in the study received antibiotics. “We don’t give antibiotics to every COPD exacerbation so this could be a factor.”

Wednesday call day. We have two rapids in the morning. One page was called for bradycardia (heart rate in the 40s). Bianca decides not to initiate any intervention, as the 75-year-old patient, admitted for hip fracture, is asymptomatic. She had received an extra dose of metoprolol due to miscommunication during the medicine reconciliation on admission; she had already taken her AM metoprolol before coming to hospital. (Our attending, Formal Frank: “This is what happens when we put elderly folk on two or three antihypertensives [amlodipine, HCTZ, and metoprolol for our patient] Have you ever heard of the Osler’s sign for pseudohypertension? No one does it anymore for some reason.” He explains how to perform the quick test to evaluate for falsely elevated blood pressure reading from a cuff due to excessively athersclerotic arteries that cannot compress. “We keep adding antihypertensives to the elderly, and our readings don’t go down until they go down. I want you to perform the test on the next elderly patient we have. Remember: Always ask, What did we do to the patient?”)

Rounds continue after the rapid with Sylvester’s 42-year-old obese female admitted two days ago after a pulmonary embolism. She is on oral birth control [OCP] and has well-controlled hypertension. She was initiated on low molecular weight heparin injections and will be transitioned to an oral anticoagulant for at least three months. Formal Frank: “A serious conversation should’ve been had with this woman several years ago. She is obese with hypertension, all risk factors for DVT, and she is still on OCPs. This could have been prevented, now she has to be on anticoagulation for at least three months, which carries its own side effects. Once again, always ask, ‘What did we do to the patient?'”

Do we need a cardiologist or hematologist consult to manage the pulmonary embolism? “I know the guidelines and studies better than most cardiologists do and feel confident in managing this disease. That’s the beauty of internal medicine, you choose what you are interested in, and get consults for things you are not interested in.” Sylvester and I spend ten minutes with our noses almost touching the screen trying to identify the occluded segmental artery on the CT angiogram without looking at the radiologist report. Sylvester: “Ah, we found it. Look at that wedge!”

Diane follows a 38-year-old overweight diabetic mother with depression and a foot ulcer admitted for a foot amputation. Her son has Down Syndrome. She will have fantastic sugar control for 8 months, but then binge for two months on pizza and soda, possibly due to “caretaker burnout.” Her affect is labile: she was extremely cheerful during pre-rounds, but now she is in tears. Formal Frank: “She’s in denial. Wouldn’t you be if you were about to lose half your foot from a small ulcer?” He continues, “If she wants to walk again, she should get a BKA [below the knee amputation] and begin PT immediately. Evidence is quite clear that the best functional outcome is from a BKA. She is unlikely to walk after this partial foot amputation, but the system doesn’t think that far forward. She’ll be back in a year requiring a BKA so what’s the damage besides a few thousand dollars, right?”

I pick up a 58-year-old patient admitted by the night team. He is admitted for acute hypoxic respiratory distress secondary to congestive heart failure (CHF), undiagnosed COPD, and atrial fibrillation with rapid ventricular response (fast heart rate). Coding for acute hypoxic respiratory distress leads to significantly enhanced revenue.

We discuss his prognosis, and if we should order an echo. The patient is on minoxidil, an old antihypertensive that is seldom used (except topically for baldness). He is also not on any CHF medications, e.g., a beta blocker or an ACE (angiotensin-converting enzyme) inhibitor,  that have a survival benefit. Formal Frank asks the team to check the chart for the name of the patient’s outside private cardiologist. “Ah, well I assure you he has had an echo in the last six months. Anything this guy can bill before the end of his patients’ life.” Sure enough, after several hours on the phone we get his outside records faxed showing echos and carotid duplex studies every six months. Although we typically do not make major changes to medications prescribed by outpatient doctors, we discontinue the modafinil and begin beta blocker and ACE inhibitor. 

This patient exemplifies the dangers of overspecialization in healthcare. The patient does not see a general internist. His (mediocre) cardiologist is essentially his primary care doctor. The cardiologist ignores everything except cardiac issues. So there are great images documenting the continued ejection fraction decline, but he is not even on the simplest albuterol inhaler for COPD. Most of the problems likely originate from the patient’s uncontrolled COPD. Over several years this leads to pulmonary hypertension, thereby leading to CHF and atrial fibrillation. We perpetuate the specialization blinds by placing an outpatient consult to pulmonology to manage his COPD rather than a consultation with a general internist. Part of this is due to insurance, Medicaid, and Medicare realities. The specialist can bill far more for the same management that could be provided by an internist, thus reducing internists to a screening function.

The nurses don’t like Sylvester’s patient, admitted for alcohol withdrawal. She and her husband have moved into the hospital. There are suitcases strewn across the room, with clothes on the floor marking a path to the hallway, despite pestering from nurses that these make it harder for them to use the blood cuff, CPAC, and other machines. Security was called after a fight over mealtimes. The patient is medically stable for discharge, but requests the ride home to which she is entitled. The social worker informs us that there are no more “Medicaid taxis” available for the afternoon. Boss Bianca: “We should’ve gotten our discharge note signed earlier. No reason to waste a whole bed for one more night.” She orders a $15 Uber on her own account to pick the couple up. The nurses cheer.

I get out around 4:00 pm on Friday. I meet Jane’s two college friends at a local brewery. Her best friend is still using U.S. student loans to complete her master’s degree in New Zealand, primarily as a way of staying in the country to be with her boyfriend. She’s writing a thesis on “sex workers” and explains the power dynamics between workers and cultural oppression.

She cites Jane’s other friend at the table as an example of a “forgotten sex worker” because she’d been hugged while working as a waitress in a small-town diner. “This older gentleman who was the diner’s best customer would expect a hug from all the younger female employees. These are the forgotten sex workers oppressed by cultural norms that I am writing about.”

[Editor: In February 2019, the New York Times covered an incident involving commercial sex at a Florida strip mall. The (undocumented) immigrant women working there were described as “prostitutes.” Native-born women working in the same industry, however, were described in previous articles as “sex workers” (example).]

We are joined for dinner by Lanky Luke and PA wife Sarcastic Samantha, and Jane’s sister and her veteran boyfriend for dinner. Jane’s sister has been completing the 22-pushup challenge for veteran suicide awareness, posting a daily Facebook video to increase awareness that an average of 22 veterans kill themselves daily. Her boyfriend was initially supportive, but now is concerned about creating a stereotype that the typical veteran is suicidal. “Few of the veteran suicides were combat veterans from Afghanistan and Iraq. They are Vietnam vets, most of whom didn’t see a day of combat. This whole PTSD phenomenon has been hijacked by non-combat vets trying to get on disability. It takes away resources from the people who actually struggle.

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Medical School 2020, Year 3, Week 20

Same rotation, but the second week of Internal Medicine brings a new attending and new residents. I get in at 6:15 am to pre-round on my two patients from the weekend (one was discharged on Sunday). I run into one of the interns for the service. Terrific Tiffany appreciates the patient summaries from Sleek Sylvester, Ditzy Diane, and myself — we are the only ones that know the patients because everyone else has left the service. Tiffany is refreshed after her 3-week stint at the resident clinic before she slaves away for a month on inpatient “wards”. We head to morning report and then directly to our new attending’s office to meet him. Formal Frank is infamous for long bedside rounds in which we present in the patient room. He expects formality and professionalism in all interactions with patients. Every time we go into the room we introduce each member of the team: “Hi, my name is Student Doctor [Sylvester].” The medical student and intern are responsible for performing a comprehensive history and physical (including neurologic exam), medications (“always have note of their medications and dose in your pocket”); the senior is responsible for presenting the assessment and plan. He also goes through expectations for an intern and resident. The resident is in charge of allocating work, a brief synopsis note, and deciding how many patients to take on the census. The intern should each hold about 7 patients. He concludes the meeting by asking Ditzy Diane, “When do you call me?” blank face. “Anytime you need me.”

His reputation does not disappoint. Rounds last until about 12:30 pm. Bianca is a little nervous because we haven’t done any “work” (writing notes, discharge orders, etc.). We each present our two patients in the room. The attending expects a full H&P instead of the shorter SOAP update note. Tiffany always adds a few items we forget. She knows everything about the patient. When we are finally done, our classmates on IM have been studying in a circle in the resident lounge for at least an hour. Gigolo Giorgio asks us, “Why are you guys all smiling?” We look at each other. “I don’t know, we’re smiling? We just got done with rounds, maybe that’s why?” 

Boss Bianca, a PGY2 internal medicine resident who completed an intern year of surgery before switching to internal medicine (3 years of training) sits down with us in the lounge after rounds while the interns hit the computers. She’s classic type-A, getting up at 4:00 am each day to read a new journal and read in her favorite Harrison’s textbook for residents, but she has an insatiable passion for teaching.

“I’m really impressed how good your presentations are for medical students. I’ve made a template that I shared with each of you for notes in the morning. Try to organize your morning presentations just like the note.” She concludes, “It’ll take us a few days to get used to how Dr. [F] wants us to work together, but we’ll have plenty of teaching times.” We work for two hours on notes before Boss Bianca pulls us over again. We go over some of her myriad powerpoints on every medical topic. Today is how to interpret a urinalysis (“UA”). 

We are pre-call so we admit four patients. Ditzy Diane takes a 50-year-old stroke patient with expressive aphasia presenting for COPD exacerbation. Diane: “It was really hard completing a history on him. His family had left when I got there.” I admit a 73-year-old lady for acute on chronic hypoxic respiratory distress secondary to COPD exacerbation and CHF exacerbation. Around 3:00 pm, we meet Formal Frank, our attending, in the ED and present our patients. Sylvester, who admitted the first patient, reads verbatim from his H&P note. I just admitted my patient around 2:30, so I do not have any time to start writing a note; instead I struggle to verbalize my disorganized notepad. 

Call day: we have several rapids and one code blue. Bianca and I get there first, and I watch her take over the show. She clearly instructs the nurses to get vitals, blood sugar, and EKG. The patient goes in and out of having a pulse. She starts checking for the 5H’s and T’s of PEA. She listens to his lungs for a pneumothorax. We do a bedside needle decompression before the attending arrives and we cart him a few rooms down to an ICU bed. 

She recounts her first rapid response as an intern. “I was called at night to a rapid response for bradycardia [slow heart rate]. We worked the patient up, and it was clear that this was caused by an overdose of her home metoprolol. The unit nursing director came in and questioned why I was not giving her atropine. There was no indication for atropine. She was not symptomatic. The unit director then called several attendings saying the intern did not know what she was doing. Two attendings arrived. I gave report: ‘patient developed bradycardia after double dose of metoprolol. Her blood pressure is 120/68, without mental status changes, pulse in 40s with no st changes on her ekg’ The nursing director was furious. I stared into her eyes  and told her to go get glucagon [a medication used for hypoglycemia, clearly not needed in this situation]. The attendings smile at me, and walk out.” Slyvester laughs, “Go get me glucagon. What a classic! You are such a boss.”

Bianca gives some handy advice: “When you first arrive, make everyone feel calm. The room should be quiet in a well run code. Assign the nurses to do specific tasks so people aren’t idly standing around. For example, get a 12-lead EKG, put the pads on, check blood glucose, and ABG. This will also highlight who doesn’t need to be in the room. People gravitate to a code situation and the room suddenly becomes packed. If there is someone crowding the room, or not following your orders, send them out of the room politely to grab something. Doesn’t matter what.” 

I admit a patient with alcoholic pancreatitis with Terrific Tiffany. I lead the interview, with Tiffany starting her H&P and placing basic admission orders on the computer. The IM service gets evaluated based upon how quickly admission orders and transfer orders are placed on ED admissions. This is the patient’s second admission for pancreatitis (2 years prior) with no change in his alcohol consumption habit. We start him on aggressive IV fluids. Tiffany quizzes me on pancreatitis management. How do we diagnose pancreatitis? How do we risk-stratify pancreatitis? I don’t give convincing answers. “The most prognostic lab value is blood urea nitrogen on admission and if it remains elevated after 48 hours. Look up the various pancreatitis score system and we’ll chat about it.” 

Over the next few days Bianca sits down with us to go over several useful topics. I appreciate her because she gives concrete examples about disease, and will provide specific data about interventions. For example, instead of saying statins are helpful in primary prevention of CV events, she will explain that statins have about a 20-30 percent relative risk reduction in cardiovascular events over 10 years. 

We have an afternoon lecture with one of our professors. We walk around the hospital in a group of six watching people walk by. We see one patient who has a diagonal ear lobe. “Frank’s sign” is more specific for CAD [coronary artery disease] than any stress test. We walk by a 50-year-old obese female with an antalgic gait [unusual way of walking in order to avoid pain]. “What do you think could be causing her pain? Look at her knees.” Ditzy Diane responds, “Her knees are bent out.” The professor continues: “Yes, look at how her leg is in valgus. Women have wider hips which make their legs into valgus strain. They are at much higher risk of arthritis and knee injuries because of this.”

We continue down to the hospital lobby to people-watch. We notice a patient with jaundice. We get distracted by our doctor going on a rant about the rise of autoimmune conditions as a result of glyphosate, the active ingredient in Round-Up. “A high dose results in the gut wall epithelial cells’ tight junctions opening up in seconds. A low dose results in gut wall opening in hours, but when you add various antigens like gluten it opens in minutes.”

[Editor: “Roundup Maker to Pay $10 Billion to Settle Cancer Suits” (New York Times, June 24, 2020): “The longest and most thorough study of American agricultural workers by the National Institutes of Health, for example, found no association between glyphosate and overall cancer risk, … The Environmental Protection Agency ruled last year that it was a ‘false claim’ to say on product labels that glyphosate caused cancer. The federal government offered further support by filing a legal brief on the chemical manufacturer’s behalf in its appeal of the Hardeman verdict. It said the cancer risk ‘does not exist’ according to the E.P.A.’s assessment.”]

Our next call day, Bianca gifts the pager to Tiffany, a bundle of nerves. Tiffany gets a page during morning report and steps out. As the ultimate demonstration of trust, Bianca doesn’t go with her. Morning report: 45-year-old real estate agent who is transported from home via EMS at 8:00 pm for  anaphylaxis. His 15-year-old daughter used her EpiPen, which likely saved his life. He reports flushing, scratchy throat and occasional hives that occur around 8:00 pm most days for the past month. In the history, we learn that he gets a burger almost every day at a diner near his work. We work him up for Alpha-Gal, or “Midnight Anaphylaxis” (delayed reaction from lone star tick leading to red meat antigen). We catch up with Tiffany walking back to the lounge and she is out of breath and sweating. “That was crazy. My first rapid alone. Oh my God that was scary.” Bianca smiles, “Awww, I remember my first rapid.” She turns to the medical students. “Rapids are way more nerve-wracking than codes. Codes you have a clear ACLS protocol. Rapids you have no idea what you’ll be walking into. You have no idea about the patient’s medical history so you have to quickly absorb the information while dealing with an acute problem.”

Statistics for the week… Study: 4 hours. Sleep: 6 hours/night; Fun: 0 nights. We do our 24-hour call on Friday. There is not much activity so the night team sends us home at 10:00 pm. We have Saturday off after morning report and return Sunday.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Medical School 2020, Year 3, Week 19 (Internal Medicine)

Internal Medicine clerkship starts at 7:00 am. My classmates and I meet the clerkship coordinator at the hospital coffee shop to receive schedules and team assignments. Gigolo Giorgio is frustrated we did not receive our schedule a few weeks ago to allow us time to plan Thanksgiving and Christmas. We can choose five days off within the next six week block in addition to two post 24-hour call days. The IM service treats weekends the same as weekdays. Giorgio complains, “I could have scheduled those five days to go home for Turkey Day.” 

Each IM team has two interns, a senior resident (PGY2 or PGY3), an attending, and a medical student pair. For this block, our team happens to have an additional (third) medical student. The attending rotates every week. 

We sip coffee as the clerkship coordinator goes through the rotation schedule for 30 minutes. The senior residents for each team come down, introduce themselves to their respective medical students, and whisks them away to meet the rest of the team. Sleek Sylvester, Ditzy Diane, and I are stuck waiting for about one hour trying to reach our senior resident. It turns out to be her day off. We locate an attending from a different team who says that three medical students should not be on one team. We follow him to locate the clerkship coordinator. She informs him that we have an extra student this rotation so the team will have to manage. 

We wait around until noon. The interns have academic half day after rounds so our entire team is off at lectures from a nephrologist. A senior resident from a different team sends us home around 2:00 pm: “Your team isn’t taking any admissions today, and the senior is off. They already finished rounds so just head home.”

The next day we get in at 6:30 am. We still do not have any patients assigned to us. Our senior resident, a 6’3″ Vermonter with a six-month-old, sits us down to go over expectations. “It is all going to depend on the attending. Some attendings will be okay with the medical student going down to the ED to interview the patient first. Some will want the intern and medical student to tag team. I’ll usually pop in to see if the patient meets admission criteria or needs ICU level of care. The most frustrating thing you’ll experience is doing a really great exam and you come up with a detailed assessment and plan, all to hear that the patient is going to go to the ICU.”

How many patients should an individual student follow? “Depending how busy we are, between 2-3 patients. I try to have medical students follow patients that they admit. Step downs and overnight admissions are always harder to understand. Leave those to the interns.” Advice for rounding and presentations? “You have to feel what the attending wants. Dr. [Bubbles] likes things a little shorter once he trusts your judgement. Watch the interns today, let’s head up for rounds.”

We head to the conference room for morning report at 7:15 am. Interview season is upon us so there are 30 fourth-year medical students (hoping to obtain residencies) in the front. Our senior resident comments, “You’ll notice that all the attendings show up on interview days, even if they have no interaction with residents at all. It’s pretty funny seeing an attending that never teaches us reflect for ten minutes about the good ole days and tidbits on how to read a CBC (e.g., monocytes are the first cell line to respond in an aplastic crisis).” A senior resident from a different team presents a case on leukostasis in acute myelocytic leukemia. Leukostasis occurs when there are so many blasts (immature blood cells from the bone marrow) in the blood that the increased viscosity leads to uncontrolled clotting and bleeding in every organ (disseminated intravascular coagulation). The patient died from a hemorrhagic stroke.

We meet our attending on the 4th floor PCU (Progressive Care Unit, with round-the-clock monitoring of vitals; essentially synonymous with “Step Down Unit”) for rounds. He’s a balding, quirky 58-year-old with round high-power glasses. Sylvester jokes that he looks like Bubbles from Trailer Park Boys. The interns are busy writing notes. We gather outside a patient’s room, and the intern presents overnight events and any changes to the current plan. If there is an overnight admission, or a new admission the attending has not seen, the intern will present a full H&P (History and Physical). The presentation is primarily an opportunity for the intern to practice articulating medical information; the attending has already looked carefully at the chart. The team then walks into the room and the attending takes over to ask the patient some questions. This may be the only time that the attending sees the patient in a 24-hour period, but Dr. Bubbles likes to return later in the day.

There are several COPD exacerbations from poor outpatient management and persistent smoking. There are two old ladies in a shared room both admitted for COPD. We are considering sending the first one to skilled rehab given her poor support system at home. The attending asks, “Do you have any help at home?” She responds: “My two sons don’t give a damn about me except for my money. You guys don’t give a damn about me.  I haven’t slept in four days, I’m just going to walk out of here. Where is my cane? God dammit, I left it at home.”

[Editor: In the Victorian era, arsenic was known as “inheritance powder.” And it would be interesting to see whether the American health care industry’s passion for elder care would survive the elimination of Medicare.]

The other lady is in a similar mood. Outside, the senior commented, “Well someone is having a bad hair day.” The attending smiled, “That will get you when you haven’t slept in four days. Let’s get her to sleep.” The intern asked, “Melatonin?” The senior responded, “No! Something that will work. Let’s try her on ramelteon or trazodone.” We finish rounds around 11:00 am. The attending returns to his office while the rest of us go to the residents’ lounge.

While the interns type at Epic, our senior resident goes over management of atrial fibrillation and congestive heart failure. Some of the medical students on other rotations join in the teaching session. We’re all clueless, even on these basic IM topics.

Sleek Sylvester and one of the interns step out for the first and only admission. Ditzy Diane and I are each assigned patients that have been here for one day. We read up on our respective patients and introduce ourselves later that afternoon. We get sent home at 3:30 pm by the senior resident: “Tomorrow is our call day, so we’ll be here pretty late. Get some studying and sleep before.”

Each team is “on call” for one or two times per week. The on-call team allocates admissions to the rest of the teams. Most teams want 12-14 patients post-call depending on the comfort of the senior resident with his or her interns. The call team also responds to all codes in the hospital outside of ICU beds. 

I get in at 6:30 am to preround on my patient, and try to get away for morning report at 7:15 am. Sleek Sylvester, Gigolo Giorgio and I lack the knack of extricating ourselves from conversations and we’re all 10 minutes late to the morning report. 

During morning report we get a page for a “code blue” (patient with no pulse). We run up seven flights of stairs (the elevators are excruciatingly slow) to find ten people standing in the room with a 60-year-old man who recently underwent a radical tonsillectomy for squamous cell cancer of the pharynx. Our Vermonter chief steps into the crowded room, which contains no doctors, and asks if anyone is leading the code. No answer. One nurse is performing CPR while another is trying to get a blood pressure. The other eight people are essentially spectators. “Fuck, okay, let’s begin.” He immediately takes over. “How long has he had no pulse?” “What happened when you walked in?” “What’s his blood pressure?” “Can we get an EKG?”

I step up to take over compressions from the nurse who is sweating and has been performing compressions for several minutes. Diane and Sylvester line up behind me and we switch every 2 minute ACLS (Advanced Cardiac Life Support, standard algorithm to respond to cardiac arrhythmias) round. The nurses say that they found him hemorrhaging “from the neck”. We activate the Massive Transfusion Protocol to transfuse 6 rounds (1 unit of blood, 1 unit of platelets, and 1 unit of FFP per round) in rapid succession. Anesthesiology and the surgical critical care teams are also paged.

The anesthesiologist shows up after five minutes and, due to all of the blood, struggles for six minutes to intubate the patient, but eventually succeeds. The surgical critical care chief arrives five minutes behind the anesthesiologist and identifies the bleeding as coming from inside the mouth, not the neck. She stuffs gauze down the patient’s throat. We  perform compressions for about 20 minutes, with his pulse coming in and out. I grab the ultrasound machine, which comes in handy when they ask for better venous access. The critical care intern places a femoral central line. We transfer the patient to an ICU bed, where his pulse returns, and then wheel him to the OR. Diane, Sylvester, and myself are all following. I tell them only one of us will be able to scrub into the surgery. We settle on Diane. But when push came to shove with the elevator doors closing, I jumped on. Sorry Diane. 

I scrub into surgery, and peek into the mouth as the ENT surgeon identifies a failed clip on the tonsillar artery. He cauterizes the pulsating artery and places several more clips. The tonsillar artery hemorrhage led to aspiration of blood leading to respiratory arrest, then cardiac arrest. The ENT surgeon asks, “Who stuffed the gauze down the throat? That saved his life. It was never hemorrhagic shock that led to cardiac arrest.” (i.e., it was blood in the lungs that starved the heart muscles of oxygen, not loss of blood).

The senior resident: “It was like something out of the movies. That was awesome. I’ve never had something like that.” Everyone, especially the medical students were congratulating him on a smoothly run code. He responded, “White coat doesn’t mean anything. You just have to take charge. Code Blues are algorithmic, it’s pretty simple compared to a rapid [Rapid Response Code] where you have no idea what you are walking into.” For me, this was the first code in which the patient actually survived. (Unfortunately, when I checked on his chart over the weekend there were notes of severe neurological deficits.)

With rounds complete, we head back to the resident lounge to work on notes for the remainder of the day. We have four rapid codes. The first was induced by a double dose of metoprolol for atrial fibrillation. She had taken one dose at home, and was given another 50 mg dose in the hospital when the doctor continued her home medications in Epic. The other three rapids were opioid-related: overdoses leading to respiratory depression and acute mental status changes. The senior instructs the nurse to administer narcan, the patient comes back. One patient had two rapid responses called because the narcan wore off. Senior resident: “Narcan is a short acting drug, some of these opioids act for a long period of time.”

The interns and I admit two patients throughout our call day. One intern is a fully licensed Iranian physician retraining so that she can practice in the U.S. and the other is a young American preoccupied with planning his next beach vacation (booze-lubricated encounters with women will be a big part). Each H&P is supposed to have a full examination including

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Medical School 2020, Year 3, Week 18 (REI)

Reproductive, Endocrinology, and Infertility (REI) elective begins at 8:00 am at the newly-constructed clinic, a 30-minute commute. I work with a 33-year-old first-year attending straight out of her three-year REI fellowship. Infertility is defined as failure to conceive after one year of unprotected intercourse. During the 45 minutes before the first couple arrives, the attending quizzes me on the basic menstrual cycle.

We see eight patients throughout the day. A typical new patient visit: the couple referred for infertility sits across from the attending’s L-shaped desk while she draws a diagram and goes over the “four pillars of conception”: (1) viable, motile sperm, (2) viable egg that ovulates (is released by the ovary), (3) open fallopian tubes for conception, and (4) implantation into uterus. (Starting with the 4th new patient, she has me draw and explain the pillars.) She will then order basic fertility labs, including a hysterosalpingogram (abdominal x-ray with contrast injected into uterus), sperm analysis of partner, ovulatory labs (Anti-Mullerian hormone, LH surge level, mid cycle progesterone), and a saline-infused sonogram evaluating the uterus cavity for implantation obstacles (e.g., intracavitary fibroid, uterine anomaly). She emphasizes that her therapies cannot fight nature’s fertility decline with age. The goal of therapy is to get back to the age-dependent cycle fertility rate.

She advises all female medical students to freeze their eggs before they hit 35.

[Editor: Better advice from a purely economic perspective would be for the prospective medical student to fertilize her eggs (with an appropriate partner and in the right state) and thus graduate debt-free.]

The clinic offers three types of fertility therapies: (1) timed-intercourse with drug-induced superovulation; (2) intrauterine insemination (IUI) with superovulation; and (3) in-vitro fertilization (about $10,000 – $15,000 per treatment). Superovulation is associated with a 5-8 percent twinning risk. Most of the couples have already done their research and been performing effective timed intercourse using over-the-counter ovulation kits. For women under 35, she recommends 2-3 IUI therapies, and, if these fail, advance to IVF.

(Why does IUI, injecting sperm into the uterus, work when ordinary intercourse doesn’t? It saves low-quality sperm some of the swimming effort.)

A woman comes in for transvaginal ultrasound prior to ovulation induction. We’re looking for 5-6 mature follicles between the two ovaries. She will have been taking letrozole (an off-label use of an inexpensive generic aromatase inhibitor used for breast cancer treatment) or clomiphene (higher risk of twinning, out-of-fashion) to stimulate superovulation. The ultrasound shows sufficient follicular development, so we instruct her to have intercourse for the next three days and, on Day 2, induce ovulation by injecting herself subcutaneously with beta-HCG (Human chorionic gonadotropin) to mimic the natural FSH/LH (Follicle-stimulating hormone/luteinizing hormone) surge.

I was fortunate to witness my attending’s first successful IUI pregnancy in this clinic. The couple tried to have kids when they were in their 20s, gave up, and returned at the husband’s initiative when the aspiring mother was 36. They cry when they see see their “little gummy bear” on transvaginal ultrasound. Nearing the end, the wife asks to see the sperm analysis, “You had mentioned something wrong with [John]’s sperm over the phone. What was it?” John comments, “Well, clearly, my sperm are good enough.” The attending jokes: “Not if you’re not the father.” The father: “I’ll have to get a paternity test now.”

[Editor: Depending on the state, if one of these two decided to end the marriage, John will have to pay child support regardless of the DNA test results. See “Who Knew I Was Not the Father?” (New York Times, November 17, 2009) for an all-American tale of extramarital love and litigation: “I pay child support to a biologically intact family,” Mike told me, his voice cracking with incredulity. “A father and mother, married, who live with their own child. And I pay support for that child. How ridiculous is that?”]

The next day we are in the OR back at the hospital. My REI attending, an intern, and I perform two hysteroscopies on women with uterine anomalies that had prevented pregnancy. The intern is not allowed to move the hysteroscope, a fiber optic cable equipped with a camera, shaver device, vacuum, and saline injector). From the first patient, we remove a uterine septum (congenital divider; first noticed during a CT scan for appendicitis). From the second, an intracavitary fibroid (smooth muscle tumor that distorts the uterine cavity lining). Both of these are covered by insurance due to their potential to cause bleeding or other medical issues unrelated to fertility.

The REI attending devotes one afternoon per week to PCOS (polycystic ovarian syndrome) cases.  We start by ignoring the elephant in the room (literally; obesity is the main cause of PCOS) and testing for extremely rare disorders that could also account for menstrual irregularity.

The first patient is typical, a 27-year-old secretary with a BMI of 34 (obesity begins at 30). She’s not planning on children in the near future, but wants to know what her prospects are. The petite fit attending lectures her on the need to lose weight, recommending cutting back on restaurant meals and making smoothies. The patient starts crying, recounting her unsuccessful attempts to lose weight.

The next patient is not typical, a 35-year-old obese female with history of bipolar disorder recently released from a state mental asylum. For her bipolar disorder, the discharge summary says that she is supposed to be on lithium, which is teratogenic (causing birth defects), but she can’t remember what medicines she is taking. She struggles for half of the visit trying to log into MyChart from her iPhone. She also has uncontrolled type 2 diabetes. Her chart shows several ED visits for substance abuse: cocaine and fentanyl. “It’s hard for me to get a job, so I want my job to be mother.” We give her pamphlets about sperm banks. The attending: “Well, that was interesting… I am not getting her pregnant. I am not sure how she even got an appointment here.”

REI is cut short by exams. As we walk into the testing center, Nervous Nancy asks, “You guys ready to look at some nasty vag pictures?” Sample questions that accompanied numerous photos of vulvar lesions:

  1. A 26-year-old female presents with nondescript vaginal discharge. A picture depicts a female with 1mm pustules on her trunk and arms. What drug would have prevented this? (Ceftriaxone to treat disseminated gonorrhea.)
  2. When do you induce labor for gestational diabetes if they are diet controlled (“A1”) versus insulin dependent (“A2”)? (41 weeks and 39 weeks) 
  3. Diagnosis of gestational diabetes using 3-hour glucose tolerance test values, requiring memorization of normal ranges.
  4. Group-B Streptococcus (GBS) prophylaxis indications if screen for GBS is negative: fever, preterm or prolonged rupture of membrane (“RoM”, over 18 hours). (give penicillin to the mom in order to prevent sepsis in the baby) 
  5. Given a chart of labor progression times, how would you classify a patient? (Students complained that the times were all in the “grey” zone between prolonged RoM and prolonged labor cutoffs.)
  6. If a mom has an abortion, what test should you always get? (Type and screen for Rhesus antigen)

(Why a screening test after an abortion? Rhesus (Rh) antigen is a sugar chain on an individual’s blood cells. If a mother who is Rh – (for example, A-) has a baby with a Rh+ father, her immune system becomes sensitized to the Rh+ antigen from recognizing the Rh+ fetus’ blood cells that cross the placenta into maternal circulation. If she does become sensitized and has another Rh+ pregnancy, the fetus will be killed by the mother’s immune system. Therefore, during any large blood volume transfer (e.g., abortion, vaginal delivery), mothers are given Rhogam, an antibody against Rh+ that binds up the Rh+ antigens before the mother’s immune system can become fully activated.)

Ob/Gyn also requires an oral examination with the clerkship director. We each go into her office for 15 minutes of questioning. We first go over a case regarding cervical cancer screening and urinary incontinence in an elderly female. We also prepared eight cases from our rotation, and she chose two to discuss (on pre-eclampsia and ovarian cancer).

After exams, I meet classmates at a new downtown brewery. Type-A Anita just finished her internal medicine rotation. “That was the first time I saw some shady medicine. A lot of the second and third year is learning about billing. You could bill for a COPD exacerbation, or you could code hospitalization as respiratory distress with hypoxia.” Lanky Luke afterwards: “Reimbursements for Medicaid patients lose money so they have to make it up by overcharging Medicare and privately insured patients. They have an army of billers to deal with this.” I respond with the positives of REI: motivated and healthy patient population, great lifestyle, no insurance hassles.

[Editor: The wise central planners in the Commonwealth of Massachusetts force private insurers to pay for in-vitro fertilization, without any limit to the number of cycles. Come to our local airport to see the business jets that the fertility doctors fly!]

Facebook status from a fourth-year medical student:  “Please read this. Even a progressive institution such as Planned Parenthood can still have unconscious bias. Wake up people! My trans friend was disappointed in his care at Planned Parenthood and switched to Hope and Help.” Underneath, a shared post from the born-female-identifying-as-a-male patient: “After dealing with fat phobia and transphobia with the nurses, as well as issues with filling my prescription, I decided it was time for a change. My doctor confirmed my fear that my dose has been far too low to yield the typical results of 9 months on T [testosterone] and worked with me to find a reliable pharmacy and be on the right dose.The staff was incredibly welcoming and I left feeling I had a voice as a patient.”

Our school can’t be accused of bias against LGBTQ community members; the Facebooking fourth-year student hasn’t had to write any tuition checks thanks to national and school-specific scholarships limited to applicants who identify as LGBTQ and/or can be characterized as part of an “underrepresented” group. The rest of the country, on the other hand, disappoints our class. From the fourth-year scholarship student, just before the 2018 elections:

I am sick and tired of being scared, and being sad, and waking up every day wondering what’s it going to be this time. Of an administration that galvanized hatred against people based on their sexuality, religion, race, ethnicity, identity. I refuse to stand for an administration that says we shouldn’t let committing sexual assault ruin a man’s life, ignoring that it has done irrevocable damage to the life and mental wellbeing of his victims. And I’ll be damned if we don’t vote these monsters out of office.” Vote for democracy. Vote for change. Vote like your life depends on it. Because it absolutely does.

From Pinterest Penelope, cheered by our school’s recent award for “diversity in higher education”:

Out of darkness, there is LIGHT! Thanks to all who work to make our university a more diverse, safe, and welcoming environment! Now, vote like your life depends on it. Because it does.

[Editor: government attacks on physicians under the Trump Administration were so severe that taxpayer spending on Medicare and Medicaid in 2017 was cut to less than $1.3 trillion (CMS.gov), projected to grow at 5.5 percent per year through 2026.]

Statistics for the week… Study: 8 hours. Sleep: 7 hours/night; Fun: 2 nights. Over beers and burgers on Saturday, Mischievous Mary talked about finishing her six-week cardiothoracic elective rotation. Lanky Luke and Jane’s eyes glaze over as she goes into details about helping to cannualize the aorta for bypass. Another exciting moment: “We were sitting at the CT surgeon lounge looking at the strips in the CCU, and we see a patient in torsades de pointes [sinusoidal wave]. We run out, and no one had noticed. We start doing compressions, pushing magnesium. It was awesome! Saved his life.”

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Medical School 2020, Year 3, Week 17 (Outpatient Gyn)

Outpatient gynecology week begins at a clinic with two nurse practitioners. Two-thirds of appointments are routine obstetric visits; one-third are gynecology visits (annuals and acute problems). Sixty percent of patients are enrolled in Medicaid; the remaining 40 percent are typically uninsured, but a social worker employed by the hospital is tasked with signing them up for Medicaid. The office runs like a typical doctor’s office… except there is no doctor. In theory, the NPs can call the inpatient gynecology attending who will drive over (20 minutes) from the hospital, but this didn’t happen during my two days.

My first patient is an outgoing postmenopausal 54-year-old botoxed blonde presenting for vaginal itching. She divorced her husband six months ago and co-founded a rental business with her handyman, with whom she now files. Their first property on the market was the ex-husband’s former house. She reports that during the early phase of her relationship with the handyman, she had sex with her ex-husband “a few times, huge mistake”. She emphasizes that for the past month she has been faithful to her new lover, but reports vaginal itchiness and discharge. She is concerned that she may have an STD. “I just pray I don’t have to tell my ex-husband. The bastard would tell my [teenage] children to turn them against me.” The NP supervises while I perform a speculum exam. I swap the cervix then prepare a wet (saline) and KOH slides to analyze under the microscope. Urine sample tests negative for chlamydia and gonorrhea. We reassure her that she does not have an STD, just bacterial vaginosis (multiple clue cells under microscope are diagnostic) and prescribe a seven-day course of Flagyl (metronidazole) 500mg BID (twice daily).

The NP schedules me for all three gynecology visits so I can practice speculum exams (nurse chaperone in room) while she keeps on time with the short routine OB. I see two OB visits on my own before she comes in. The last patient I see jointly with the NP. She is a withdrawn 17-year-old G2P1 at 16 weeks presenting for her initial OB visit. She is accompanied by an older sister. I communicate the schedule of upcoming OB visits (e.g., 20-week anatomy scan, glucose tolerance test, bacteriuria screening, Rhogam at 28 weeks, etc.). “I’ll have to make sure I can get out of school and that my sister can drive me.” The older sister says that she hopes the soon-to-be-mother-of-two will stay in high school and graduate. “Is the father aware of the child?”  The older sister responds, “Yes, he’s in school, but isn’t going to be involved. Our parents are going to take care of the new baby.”

After the visit, the NP recounted her experience as a nurse on the obstetrics triage floor. “We had a 12-year-old come in for a missed period. We asked the patient if she was having sex. No. Intercourse? No. Then a resident finally comes up and says: ‘Are you doing it?’ ‘Well yeah, I’m doing it.’ We immediately started to get worried about incest. Back in the day you’d get worried about a 12-year-old having sex. Now we don’t even bat an eyelid.”

I leave at 3:00 pm for the afternoon gynecologic oncology lecture. Our attending goes over the common gynecologic cancers: ovarian, endometrial, and cervical. She summarizes: “Ovarian cancer patients die of malnutrition, endometrial cancer patient die of a heart attack [patients are generally  obese with multiple comorbidities].” She continues: “Does cervical cancer run in families?  After a pause, Nervous Nancy responds, “No, it’s not a genetic disease, it’s about behavioral risk factors — HPV exposure and smoking.” The attending answers: “You’re correct about the risk factors, but cervical cancer does end up clustered in families because failure to access the health care system runs in families. My cervical cancer patients have not been to the doctor in over 10 years, or at least haven’t gotten a pelvic exam in 10 years. Sometimes they have been seen by an internist a few times who just have given up performing pelvic exams in their practice. Cervical cancer patients die of renal failure, that’s a good death. Uremia, you just fall asleep. The patients are young, typically 50 years old but it’s a good death unlike ovarian cancer.” (The working lower middle class are in the worst shape for access, suffering from massive insurance co-pays and being ineligible for the various free care options.)

She describes the challenges of patients consuming online information and the Power of the Pink Ribbon. “I had a sister who sent me an article saying OCP [oral contraceptive pills] increase the risk of breast cancer. I followed the link and it cited a 2014 article assessing high-dose estrogen-only pills, which are never used now. It just shows you how much false information is online. This stuff can impact your health. OCPs actually prevent breast and gynecologic cancers.” She continues: “Now keep in mind the vast majority of women who get breast cancer do not have ANY of the risk factors we talk about.  There is a high enough baseline risk that every woman over 45 should be getting a mammogram.”

[Editor: See “National expenditure for false-positive mammograms and breast cancer overdiagnoses estimated at $4 billion a year.” (2015), a study done using the insurance claim database that we have at Harvard Medical School. “Populationwide mammography screening has been associated with a substantial rise in false-positive mammography findings and breast cancer overdiagnosis.” Many of the lives saved from cancer that have been chalked up to mammograms were in women who did not actually have cancer. It turns out that waiting for a lump is as reliable a way of finding true cancers as mammography. Switzerland, which spends much less on health care and enjoys longer life expectancy, has eliminated routine screening mammography. The U.S. meanwhile, is doubling down on medical interventions. The government issued a February 11, 2019 recommendation to put all higher-risk women on aromatase inhibitors.]

On Wednesday, I am in a different outpatient clinic: the “resident clinic” for high-risk OB. This one is led by a 5’4″ no-nonsense PGY4. My first patient is an uncontrolled obese T2DM G3P2002 (type 2 diabetes; third pregnancy; two babies delivered at term; zero pre-term; zero miscarriages; two living children) presenting for her initial OB visit at 8 weeks. I go in first to get a history and complete a basic physical with doptone heart rate, waiting for the resident before beginning the pelvic exam. The unkempt diabetic single mom does not check her sugars. She hasn’t followed up with her endocrinologist because she owes $150 (she should be eligible for Medicaid, but hasn’t jumped through all of the paperwork hoops). 

The patient describes vaginal discharge. We perform a speculum exam. I have to hold up several abdominal folds leading to a foul smell from candidiasis (yeast infection) while the resident performs the exam. We explain that she needs to use contraception if she doesn’t want to get pregnant again. “Those pills bad for the body.” (She may be correct; her uncontrolled hypertension is a contraindication for oral contraception.) The resident: “Yes, but it’s also unhealthy to keep having unwanted pregnancies, especially when you are overweight and have uncontrolled blood sugar.” She says she will consider contraception, but rejects the offer of an IUD insertion after delivery. The resident gets frustrated when her lecture on risks to the baby from uncontrolled diabetes is interrupted by incoming calls and texts on the Medicaid-eligible patient’s unsilenced iPhone X.

After several obese women described by the resident as  “simply refusing to take care of themselves, let alone their multiple kids,” I see a young immigrant couple. They earn too much to qualify for Medicaid, but found that insurance was unaffordable. The 24-year-old Indian 26-week nullip has a normal BMI, but was diagnosed with gestational diabetes at screening.  The husband brings a notebook of sugar logs. I circle two fasting and one 2-hr postprandial sugar value that were elevated within the past two weeks. Wow! I present the patient to my resident. “If they are tracking their sugars, they have good sugars,” the resident explains. “For every five terrible patients, many of whom have several children in foster care, you see a couple like this one. I’m glad you were able to see them. They can’t afford private practice so they come here, and they will be terrific parents.”

The outpatient clinic employs a full-time Spanish-language medically certified interpreter and she is present for roughly 50 percent of the visits. Visits with a Mandarin-speaking patient and an Arabic-speaking patient are cumbersome. Within the hospital, full-time Mandarin and Arabic interpreters are available in person. From the clinic, however, we use a phone-based service for interpretation, but it isn’t nearly as efficient as having a live interpreter in the room.

[Career tip from the Editor: the typical certified interpreter earns about $35/hour, or $70,000 per year working full time.]

Jane is on inpatient pediatrics. “After rounds we sit at a table finishing notes on our laptops. After a while, she does UWorld questions. She is partnered with Awkward Arthur, a 5’5” Asian 28-year-old who has had to remediate following most clinical skills exams. “He keeps looking over my shoulder. I eventually ask if he wants to do questions with me. And he starts trying to show me up. He does this in rounds too. He seems innocent, but he is a total gunner.”

Statistics for the week… Study: 4 hours. Sleep: 7 hours/night (showtime for outpatient work is 8:00 am); Fun: 2 nights. We see an Americana jam-band at a church turned into a concert hall by a local foundation with Sarcastic Samantha and Lanky Luke.

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Medical School 2020, Year 3, Week 16 (Inpatient Gyn)

Gynecology rotation starts at 7:30 am in the outpatient surgery center. The chief texted the previous night to skip hospital rounds and just meet the team at the outpatient surgery center for the first 8:00 am case (this is an inpatient week, but if there are no scheduled surgeries at the hospital we go with an attending to the outpatient center). I appreciate the extra sleep! Our first patient is a 27-year-old who had an unfortunate uterine perforation after IUD placement by a Planned Parenthood Nurse Practitioner. “I think it was her first IUD placement. Looking back, she was so nervous.” After a brief physical, we have about 30 minutes before the OR is ready.

Did it hurt getting the IUD placed? “It hurt so bad, but they told me that’s expected. Over the next week, the intense pain got better, but I just kept having these sharp lightning bolts of pain once or twice a day.” She saw an Ob/Gyn for a regular check up three months later who ordered an abdominal x-ray that showed a “T”-shaped device in the right upper quadrant. 

The 70-year-old attending arrives. She meets the patient and confirms the consent is signed. I grab gloves for the attending, the intern and myself. We perform a laparoscopic removal of the IUD. It was lodged in the omentum requiring three port placements (three holes in the belly). Throughout the entire procedure, the 60-year-old anesthesiologist, a former dentist, tried to convince me that anesthesia is the best route. “Hospitalists are miserable,” he began. “They have 80 patients, they work 12-hour shifts. It’s not good for the patient, but it’s the way medicine has gone. In anesthesia, we have only one patient at a time, and we are done after you leave the office. And the physiology is just awesome.”

As the OR is prepared by the nurse, surgical tech, and OR tech,s for the next case, we head to post-op to talk to our recovering patient. After a brief conversation with the patient and her mother, we head to the nurse’s station where the intern is instructed to prescribe 10 OxyContin 5 mg. “It’s crazy how much opioid pills we still give out. Epic defaults to 30 pills for a prescription,” says the attending. “I still have dozens of narco left over from my breast cancer surgery. Everyone is talking about the opioid problem and how doctors created this monster, perhaps, but I still blame the government. They started to adjust reimbursement rates based on patient-reported pain scales. No wonder the ED gave out Oxy like candy.”

Before our next procedure (hysteroscopy, camera through the cervix into the uterus to look for, and possibly biopsy, cancerous polyps), I chat with the attending about the future of Ob/Gyn: “Ob/Gyn was a beautiful field because it combines surgery with long-term patient relationships. I am the primary care provider for a lot of my patients. We’re succumbing to the specialization tsunami. I’ve been grandfathered in, but most hospitals require you to choose a track: gynecology or obstetrics.” She continued, “The days of having clinic in the morning with two afternoons of gyn surgeries alternating with a week of obstetrics are ending. Administration is chipping away at the scope of practice for every field.”

After a total of three procedures, I leave the outpatient OR at noon to attend lectures at the hospital on urinary incontinence by a “UroGyn” (Urogynecologist, 4-year OB/Gyn residency followed by 3-year fellowship). 

The next day starts with hospital rounds before surgery at 6:30 am in the main hospital OR. We have two laparoscopic fibroid removals and a hysterectomy scheduled. Dr. McSteamy is the attending. He is a 37-year-old whose recent marriage occasioned despair among the residents (all female, except for one gay guy, a junior resident, who shared their grief). The chief, now four years out of medical school, struggles with basic laparoscopic techniques, incorrectly locating the ureters, a critical item given the risk of damage during the procedure. She also has a six-month-old at home, which might explain some of her deficiencies, but her parents have moved here to assist the software engineer husband in taking care of the baby. She is trying to find a job next year as a general practitioner in a smaller hospital setting. 

During the second hysterectomy, the junior resident gets a page for two ED admits. He and I step out to evaluate a 24-year-old bartender with a three-day history of excruciating labial pain. She had a similar episode several years ago. Her right labia majora is swollen, erythematous (reddened), and extremely painful when she walks or moves. As I prepare to present the findings to Dr. McSteamy, I look up management of Bartholin abscess in my trusted Comprehensive Handbook of Obstetrics and Gynecology by Zheng, a $30 book that fits into a scrubs pocket. The bartholin glands, located at 4 and 8 o’clock in the vaginal introitus, secrete lubricating fluid through a small duct. Some women develop a blockage in the duct leading to an enlarging cyst that becomes infected. Once McSteamy is out of surgery, we head down as a team to examine the patient. We then gather supplies (numbing medication, Wort catheter, scalpel, iodine prep) to drain the abscess. Before we go in, the ED attending asks if the resident has performed one of these. No. Dr. McSteamy then describes the procedure. The ED attending also wants to watch as she has never seen one performed. We transfer the patient into an ED procedure room with stirrups. The resident injects lidocaine in the 3 cm labial abscess and she cries out in pain. After 5 minutes, the resident makes a small incision in the labia, which results in screams and “sorry, sorry.” He then slips a 3 mm-diameter drainage catheter into the abscess. She is supposed to leave this in for 2-4 weeks, but the attending admits that most will fall out within a week. If this happens again she might consider getting a bartholin gland excision or marsupialization surgery (turns the gland inside-out) to maintain duct patency

Friday morning: round on two post-op patients and then am sent off to study before a mandatory class meeting at 1:00 pm. Nervous Nancy is in the student lounge watching Grey’s Anatomy on her phone. She is on outpatient Ob/Gyn week and was told not to bother driving to the clinic today. “Whenever I get nervous before exams, I instinctively watch Grey’s Anatomy. My excuse is I might learn something from it while calming my nerves by binge-watching.” We talk about her experience on Obstetrics. “I sometimes think, screw I am going to have a baby even though I am vastly irresponsible and underprepared. Look at these moms. Then I remember that they are terrible people.” I recount my experience with the G9P8 having the ninth baby. When asked why she keeps having babies, she responds: “Well all my children are in foster care so I need to have another one to actually keep one.” Nervous Nancy laughs, and says, “I’ve seen those too. Maybe your children are in foster care because you are a crack addict.”

We head over to the school for confessions of a medical student. We were instructed to prepare by writing a two-paragraph anonymous confession from this year. We are divided into 10-person groups, each led by a physician who shuffles them and hands them out for presentation: 

  1. Dear patient, I know everything about you. I know your STD history, I know you have had more children than reported to your husband, and I know your mother died from colon cancer. But as I walk through the door I realized I forgot your name. Unnamed patient, I am sorry.
  2. We were so rushed one day on rounding that we didn’t not explain to a patient why we were performing a digital rectal exam. I felt we violated his dignity. We were trying to rule out colon cancer.
  3. I resent when doctors say “we have it so much easier than you did”. They don’t understand the stresses we are under from residency competitiveness and financial costs.
  4. It is such a relief to see bad doctors practicing. The imperfection reminds me that I don’t have to be perfect to become a doctor. Being a doctor is human, and humans are imperfect. Some are even bad at their job.
  5. I learn more from watching bad doctors make mistakes than from good doctors.
  6. We had a patient whose biopsy was delayed because of another patient requiring a more urgent read. We joked how annoying he was. He started to yell that he was going to sue the hospital so the team disliked him even more for him being so difficult. He started to have delirium. When I went in alone to check on him in the morning he was clam and present. He confided in me: “I don’t care about myself, my wife is not strong enough to handle another day of not knowing.” The wife broke down in the room. He then got delirious and started asking philosophical questions, “Where are you going?”, “Are you content?”, “What happens next?” It gave me chills.
  7. I can never do pediatrics. An anti-vaxxer mom and her three kids came to the pediatric clinic for a first visit after getting thrown out by their prior pediciatrian. The kids asked me why they can’t go to normal school instead of being homeschooled. It was terrifying seeing a crazy woman make decisions that will impact these kids’ lives with no one to stop her.
  8. We don’t do much good in the hospital or in medicine. So much waste, discharging patients for them to come back in a week. We just use all this expensive technology that prolongs a miserable life. The best care I’ve seen so far was when a surgeon decided to not operate and recommended comfort care.
  9. I kept telling my team that a patient had a certain diagnosis, albeit atypical presentation. They kept saying how it could never be that, and made fun of me. After a few days and it turned out I was right, but they never acknowledged what I had told them. In my evaluation they mentioned only trivial stuff: on time, attentive, knows patients.
  10. I feel disillusioned. Despite all this training I feel worthless and unable to manage any real problems my friends and family ask me about. Barbara Freiderson helped me: “The negative screams at you, but the positive only whispers.”

Nervous Nancy: “I just feel like I am always in the way. That no one is grateful for us, and the people that actually care for the patient would have it easier without us present.” The physician leader asks, “Do any of you wish you were invisible?” Every student grinned, and nodded. Gigolo Giorgio, who sports a beer belly after gaining several pounds on psychiatry, comments: “I think you mean we all want to be flatter against the wall.”

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 1 night. Halloween celebration. Gigolo Giorgio hosts a pregame before the class Halloween party downtown. We reminisce about our rotation experiences. Buff Brad and his girlfriend dress up as Gamora and Warlock from Guardians of the Galaxy, Adrenaline Andrew and his girlfriend win first prize with homemade jellyfish costumes out of Christmas lights and clear umbrellas. Classmates are downing shots and beer. Once we arrive at the rented out bar’s upstairs room, students dance Top 25 Pop hits while a line grows at the private bar for $5 mixed drinks. Gigolo Giorgio jokes: “[Put-Together Pete] is on his 24-hour night shift for surgery, we should all get blackout and visit him in the ED.”

The rest of the book: http://fifthchance.com/MedicalSchool2020

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Medical School 2020, Year 3, Week 16 (Inpatient Gyn)

Gynecology rotation starts at 7:30 am in the outpatient surgery center. The chief texted the previous night to skip hospital rounds and just meet the team at the outpatient surgery center for the first 8:00 am case (this is an inpatient week, but if there are no scheduled surgeries at the hospital we go with an attending to the outpatient center). I appreciate the extra sleep! Our first patient is a 27-year-old who had an unfortunate uterine perforation after IUD placement by a Planned Parenthood Nurse Practitioner. “I think it was her first IUD placement. Looking back, she was so nervous.” After a brief physical, we have about 30 minutes before the OR is ready.

Did it hurt getting the IUD placed? “It hurt so bad, but they told me that’s expected. Over the next week, the intense pain got better, but I just kept having these sharp lightning bolts of pain once or twice a day.” She saw an Ob/Gyn for a regular check up three months later who ordered an abdominal x-ray that showed a “T”-shaped device in the right upper quadrant. 

The 70-year-old attending arrives. She meets the patient and confirms the consent is signed. I grab gloves for the attending, intern and myself. We perform a laparoscopic removal of the IUD. It was lodged in the omentum requiring three port placements (three holes in the belly). Throughout the entire procedure, the 60-year-old anesthesiologist, a former dentist, tried to convince me that anesthesia is the best route. “Hospitalists are miserable,” he began. “They have 80 patients, they work 12-hour shifts. It’s not good for the patient, but it’s the way medicine has gone. In anesthesia, we have only one patient at a time, and we are done after you leave the office. And the physiology is just awesome.”

As the OR is prepared by the nurse, surgical tech, and OR tech,s for the next case, we head to post-op to talk to our recovering patient. After a brief conversation with the patient and her mother, we head to the nurse’s station where the intern is instructed to prescribe 10 OxyContin 5 mg. “It’s crazy how much opioid pills we still give out. Epic defaults to 30 pills for a prescription,” says the attending. “I still have dozens of narco left over from my breast cancer surgery. Everyone is talking about the opioid problem and how doctors created this monster, perhaps, but I still blame the government. They started to adjust reimbursement rates based on patient-reported pain scales. No wonder the ED gave out Oxy like candy.”

Before our next procedure (hysteroscopy, camera through the cervix into the uterus to look for, and possibly biopsy, cancerous polyps), I chat with the attending about the future of Ob/Gyn: “Ob/Gyn was a beautiful field because it combines surgery with long-term patient relationships. I am the primary care provider for a lot of my patients. We’re succumbing to the specialization tsunami. I’ve been grandfathered in, but most hospitals require you to choose a track: gynecology or obstetrics.” She continued, “The days of having clinic in the morning with two afternoons of gyn surgeries alternating with a week of obstetrics are ending. Administration is chipping away at the scope of practice for every field.”

After a total of three procedures, I leave the outpatient OR at noon to attend lectures at the hospital on urinary incontinence by a “UroGyn” (Urogynecologist, 4-year OB/Gyn residency followed by 3-year fellowship). 

The next day starts with hospital rounds before surgery at 6:30 am in the main hospital OR. We have two laparoscopic fibroid removals and a hysterectomy scheduled. Dr. McSteamy is the attending. He is a 37-year-old whose recent marriage occasioned despair among the residents (all female, except for one gay guy, a junior resident, who shared their grief). The chief, now four years out of medical school, struggles with basic laparoscopic techniques, incorrectly locating the ureters, a critical item given the risk of damage during the procedure. She also has a six-month-old at home, which might explain some of her deficiencies, but her parents have moved here to assist the software engineer husband in taking care of the baby. She is trying to find a job next year as a general practitioner in a smaller hospital setting. 

During the second hysterectomy, the junior resident gets a page for two ED admits. He and I step out to evaluate a 24-year-old bartender with a three-day history of excruciating labial pain. She had a similar episode several years ago. Her right labia majora is swollen, erythematous (reddened), and extremely painful when she walks or moves. As I prepare to present the findings to Dr. McSteamy, I look up management of Bartholin abscess in my trusted Comprehensive Handbook of Obstetrics and Gynecology by Zheng, a $30 book that fits into a scrubs pocket. The bartholin glands, located at 4 and 8 o’clock in the vaginal introitus, secrete lubricating fluid through a small duct. Some women develop a blockage in the duct leading to an enlarging cyst that becomes infected. Once McSteamy is out of surgery, we head down as a team to examine the patient. We then gather supplies (numbing medication, Wort catheter, scalpel, iodine prep) to drain the abscess. Before we go in, the ED attending asks if the resident has performed one of these. No. Dr. McSteamy then describes the procedure. The ED attending also wants to watch as she has never seen one performed. We transfer the patient into an ED procedure room with stirrups. The resident injects lidocaine in the 3 cm labial abscess and she cries out in pain. After 5 minutes, the resident makes a small incision in the labia, which results in screams and “sorry, sorry.” He then slips a 3 mm-diameter drainage catheter into the abscess. She is supposed to leave this in for 2-4 weeks, but the attending admits that most will fall out within a week. If this happens again she might consider getting a bartholin gland excision or marsupialization surgery (turns the gland inside-out) to maintain duct patency

Friday morning: round on two post-op patients and then am sent off to study before a mandatory class meeting at 1:00 pm. Nervous Nancy is in the student lounge watching Grey’s Anatomy on her phone. She is on outpatient Ob/Gyn week and was told not to bother driving to the clinic today. “Whenever I get nervous before exams, I instinctively watch Grey’s Anatomy. My excuse is I might learn something from it while calming my nerves by binge-watching.” We talk about her experience on Obstetrics. “I sometimes think, screw I am going to have a baby even though I am vastly irresponsible and underprepared. Look at these moms. Then I remember that they are terrible people.” I recount my experience with the G9P8 having the ninth baby. When asked why she keeps having babies, she responds: “Well all my children are in foster care so I need to have another one to actually keep one.” Nervous Nancy laughs, and says, “I’ve seen those too. Maybe your children are in foster care because you are a crack addict.”

We head over to the school for confessions of a medical student. We were instructed to prepare by writing a two-paragraph anonymous confession from this year. We are divided into 10-person groups, each led by a physician who shuffles them and hands them out for presentation: 

  1. Dear patient, I know everything about you. I know your STD history, I know you have had more children than reported to your husband, and I know your mother died from colon cancer. But as I walk through the door I realized I forgot your name. Unnamed patient, I am sorry.
  2. We were so rushed one day on rounding that we didn’t not explain to a patient why we were performing a digital rectal exam. I felt we violated his dignity. We were trying to rule out colon cancer.
  3. I resent when doctors say “we have it so much easier than you did”. They don’t understand the stresses we are under from residency competitiveness and financial costs.
  4. It is such a relief to see bad doctors practicing. The imperfection reminds me that I don’t have to be perfect to become a doctor. Being a doctor is human, and humans are imperfect. Some are even bad at their job.
  5. I learn more from watching bad doctors make mistakes than from good doctors.
  6. We had a patient whose biopsy was delayed because of another patient requiring a more urgent read. We joked how annoying he was. He started to yell that he was going to sue the hospital so the team disliked him even more for him being so difficult. He started to have delirium. When I went in alone to check on him in the morning he was clam and present. He confided in me: “I don’t care about myself, my wife is not strong enough to handle another day of not knowing.” The wife broke down in the room. He then got delirious and started asking philosophical questions, “Where are you going?”, “Are you content?”, “What happens next?” It gave me chills.
  7. I can never do pediatrics. An anti-vaxxer mom and her three kids came to the pediatric clinic for a first visit after getting thrown by of their prior pediciatrian. The kids asked me why they can’t go to normal school instead of being homeschooled. It was terrifying seeing a crazy woman make decisions that will impact these kids’ lives with no one to stop her.
  8. We don’t do much good in the hospital or in medicine. So much waste, discharging patients for them to come back in a week. We just use all this expensive technology that prolongs a miserable life. The best care I’ve seen so far was when a surgeon decided to not operate and recommended comfort care.
  9. I kept telling my team that a patient had a certain diagnosis, albeit atypical presentation. They kept saying how it could never be that, and made fun of me. After a few days and it turned out I was right, but they never acknowledged what I had told them. In my evaluation they mentioned only trivial stuff: on time, attentive, knows patients.
  10. I feel disillusioned. Despite all this training I feel worthless and unable to manage any real problems my friends and family ask me about. Barbara Freiderson helped me: “The negative screams at you, but the positive only whispers.”

Nervous Nancy: “I just feel like I am always in the way. That no one is grateful for us, and the people that actually care for the patient would have it easier without us present.” The physician leader asks, “Do any of you wish you were invisible?” Every student grinned, and nodded. Gigolo Giorgio, who sports a beer belly after gaining several pounds on psychiatry comments: “I think you mean we all want to be flatter against the wall.” 

Statistics for the week… Study: 10 hours. Sleep: 6 hours/night; Fun: 1 night. Halloween celebration. Gigolo Giorgio hosts a pregame before the class Halloween party downtown. We reminisce about our rotation experiences. Buff Brad and his girlfriend dress up as Gamora and Warlock from Guardians of the Galaxy, Adrenaline Andrew and his girlfriend win first prize with homemade jellyfish costumes out of christmas lights and clear umbrellas. Classmates are downing shots and beer. Once we arrive at the rented out bar’s upstairs room, students dance Top 25 Pop hits while a line grows at the private bar for $5 mixed drinks. Gigolo Giorgio jokes: “[Put-Together Pete] is on his 24-hour night shift for surgery, we should all get blackout and visit him in the ED.”

The rest of the book: http://fifthchance.com/MedicalSchool2020

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