Category: Medical School

Week 2 of inpatient psych. The resident is late for the 8:30 am handoff, so I talk to the night resident. There were two “soft” admissions (people who could have gone home) overnight, which I relay to the team for 9:00 am rounds. Robin Williams is frustrated that the night team put several patients on one-to-one precautions (patient cannot have a roommate), and did not re-evaluate them throughout the shift.  “Guess they didn’t want to do any work.”  

The 46-year-old white female with a history of MDD (major depressive disorder) and childhood abuse presents for suicidal ideation without plan. She described her abuse as a child: “Let’s just say my mother would put me on the hood in the driveway, accelerate briefly and slam the brakes. And she was the nice one.” She currently takes care of her husband, who is on dialysis for end-stage renal disease due to uncontrolled diabetes and hypertension. “My mother-in-law has been yelling at me all the time. She doesn’t think any decision I make is right for her son. She’s not the one taking care of him everyday. She comes into our house once a week, and smothers him with love, bakes cookies, and changes his sheets. So now my husband thinks I am inadequate.” She concludes: “I would have been fine if I just talked to my therapist, but it was a Sunday.” 

After lifting a one-to-one precaution, we are able to admit a 40-year-old white female with MDD who arrived late last week in the ICU for an overdose of Xanax (one bottle). “It’s hard to kill yourself by overdosing on benzos,” says the attending, reviewing her chart and seeing a prescription for oxycodone for back pain. “But add a pinch of opioid, and boom, there goes your respiratory drive. She’s lucky that she didn’t take any of her oxy. We’ll keep that little secret to ourselves. Not all patient education is good.” He continues, “It’s my understanding this was a completely spontaneous overdose attempt without any contemplation. These are the people who will end up killing themselves. Really hard for the family to intervene.”

New this month is a hospitalist stationed on the inpatient psych unit tasked with medically optimizing patients. The psychiatrists see this as a revenue-maximizing gimmick. “We don’t need a damn echo on this patient. Who cares about a new murmur when she just overdosed on Xanax? What’s going to kill her?”

(Two days later, she had yet to get out of bed or interact with anyone. While the resident and I are interviewing her, the attending jumps in and shocks us by scolding her to get out of bed and attend group sessions if she wants to be released.)

Afterwards he explained to me: “The goal of our interaction is not for me to make the patient feel bad, make me virtuous and show the patient how much smarter I am compared to her. If I need to be the bad cop and let nurse Tammy be the good cop, then so be it… Even if satisfaction is how I’m now being graded on. I’ll take a hit if it gets the patient out of bed and moving forward.”

He continues: “Unfortunately, health systems are realizing that it is cheaper and more profitable to hire 12 ACPs [advanced care practitioner, e.g., physician assistant or nurse practitioner] who write expensive medications over shorter visits with only one supervising doctor instead of focusing on counseling.”

Our psych practice has been profitable enough that we’ll get a brand-new building 18 months from now, but in the intervening time all of the hallway door handles are going to be replaced to comply with a new regulation to prevent patients from choking themselves with sheets tied to handles. Robin Williams: “A $2 million renovation for a building that will be knocked down soon. But what am I supposed to do?”

After rounds, Robin Williams invites me to walk with him to the main hospital and join for a consult with the endocarditis service. “Endocarditis [infected heart valve] used to be a disease of the immunocompromised, but now is almost entirely IV heroin and meth users. Cardiothoracic surgery will replace an infected valve and just for a few months later the patient, who will have resumed recreational IV drug use with non-sterile equipment, will present with an infected replacement valve. In addition to the replacement valve, endocarditis treatment requires six weeks of IV antibiotics so we start them on Suboxone in the hospital and get them set up with MAT [medication assisted therapy] to see if this will decrease the rate of using again.”

[Editor: this reflects the American best practice of treating people who are addicted to opioids by giving them an addictive opioid (Suboxone). Note that if this works out as planned, the health system gets to bill Medicaid for surgery, a six-week hospital stay, and a lifetime of Suboxone therapy.]

The first patient, a 31-year-old white male, is angry at the nursing staff because he signed the Suboxone documents without realizing that he was agreeing to his visitors being searched, a policy enacted after quite a few visitors brought drugs to patients during their six-week IV antibiotic stays. His girlfriend was caught last week injecting an unknown substance via his IV catheter.  Robin Williams talks to the patient about working together to get sober. The patient explains that he tried methadone and Suboxone and claims to be allergic to Suboxone. Robin Williams: “You tried methadone? How long?” He responds that he visited the clinic for a month. “Wow, that takes a lot of dedication. You should be proud of sticking with it for a month.” He concludes: “Now I am willing to work with you. You say you are allergic to Suboxone, I will give you buprenorphine. You have to start a MAT program at [our institution]. People who are on buprenorphine get monitored a little closer, so one wrong step and you will be out of the program.” The next endocarditis patient is a “VIP” (politician) so I am sent back to the inpatient psychiatry unit.

At noon, I attend the twice daily music and art therapy group sessions. The art therapist passes out paper and coloring instruments to all the participants. The schizophrenia patient walks into the room, and sits behind on the cafeteria tables. He somehow obtains a sharpened color pencil, which makes everyone nervous. The therapist then asks each participant to pull a slip of paper out of a hat. We then draw a picture based on the word written on the slip. My word was “crossroads.”

After 30 minutes of art, we begin one hour of music. We go around the room each selecting a song to be played on a bluetooth speaker. The only rules: (1) no curse words, and (2) the therapist has the right to stop the song. A heroin addict starts with “It’s Been Awhile” by Staind. The therapist has to stop the song after a minute when the polysubstance users start nodding their heads and one says, “Oh yeah, gotten high to this lots of times.” A benzo and opioid addict plays a song by 5 Punch Death Metal. A 56-year-old alcoholic plays “Seen it in Color” by Jamey Johnson, which triggers a 34-year-old opioid addict who excuses himself with tears in his eyes. We then transition to group drumming. The music therapist passes around drums to each participant. Each member is allotted a 10-second solo to “bang out” his or her feelings.

At 3:00 pm, I attend the psychiatry lecture series. Out of the 52 weekly lectures, psych gets to pick one as an annual required talk for the internal medicine residents. Today’s lecture on “Gender-Affirming Treatment Overview” has been picked as information that internal medicine doctors need to hear. The PGY-3 begins: “The first important takeaway from this talk is that gender dysphoria is not a disease. We are still fighting this misconception because DSM-3 [Diagnostic and Statistical Manual of Mental Disorders, 1980s edition] had this under ‘delusional disorder’.”

“Current literature supports the ‘Minority Stress Theory’ in which external prejudice leads to internal stress and depression,” she continues. “This results in the high risk of depression and suicide seen in GD [gender dysphoria].” We then go through the UK’s Coming Out guide online. There are minimal specifics about how to initiate hormonal replacement therapy, the contraindications, etc. Much of the time was focused on discussing how to label patients in Epic. The Chief Information Officer of our hospital is in the audience and jumps in: “This has been an ongoing struggle because there is no good solution. We don’t want to change the sex designation because then it would change many screening algorithms [e.g., if female over 40, ask about mammograms] and create insurance issues. We have worked extensively to roll out a new Trans disclaimer.” (It might have been better if his office had worked harder on security; our institution was recently the victim of a ransomware attack.)

We have a 3:30 pm admission for a 21-year-old transgender male (female to male) with a history of bipolar disorder and polysubstance use presenting for suicidal ideation. The patient has a deep bass voice and cystic facial acne. Psychosocial stressors include: (1) missed appointment to get testosterone shot last month; (2) broke up with girlfriend during preparations for a marriage proposal; and (3) inability to reconnect on Facebook with an ex-girlfriend with whom the patient feels an “incredibly deep connection”. The patient shuts down after this description: “I do not want any help, I just want my testosterone shot.” During rounds the next morning, the social worker notes that she did intake on him in the ED six months ago. “He was saying he was a transgender female. Look, it’s in my note… and other notes from before. He’s got to get his story straight!” 

Robin Williams: “Everyone talks about evidence-based medicine, but there is no evidence gender-affirming treatments improve patient outcomes like suicide rate. All the studies use subjective outcomes. What I find is that they become fixated on HRT [hormonal replacement therapy] as the solution to all their problems.”

Our last patient for the week is a 34-year-old contractor with opioid use disorder. He was kicked out of a Suboxone clinic for a dirty urine drug screen (positive for cocaine). He’s been buying Suboxone on the street to prevent opioid withdrawal, but hasn’t been able to find much. The social worker is trying to get him back into the Suboxone program, but it will take between 1-2 months for the next intake. The attending agrees to write a prescription bridge of Suboxone. 

“Some of the highest level of opioid use is in the contractor community,” explains the attending. “I was getting a remodel done on my house and it was impossible to have anyone reliable. They work for their pay check to buy pills. Then I found a Mexican family who would arrive an hour early and pile out of their van. They finished the job two weeks early.”

This week I felt part of the team. I wrote notes on half the patients, including assessment and plan (e.g., medication changes, social worker communication, etc.) with minimal edits by the resident and signed by the attending, and I helped with determining if medical evaluation is necessary. I see several patients that need medical care. We prescribe penicillin for strep pharyngitis. I evaluate someone for LE pain with a raised leg test [rule out cauda-equina syndrome]. I recommend someone follow up with neuro for a parkinsonism tremor and bradykinesia.

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Buff Bri, Ambitious Al, Jane, Straight-Shooter Sally, and I go to a local Blues/Jazz club. We dance the night away. 

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

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The clinic staff throws a party for my last day. One of the secretaries brought in homemade rhubarb turnovers. I express my gratitude and they respond with “We take any excuse to throw a party!” I am sorry to bid farewell to Doctor Dunker.

Family Medicine students then go to a culinary medicine workshop at the YMCA. Our school gives us each of the five groups a Visa gift card to buy food for a hypothetical family of four, one of whom has a medical issue, e.g., a diabetic child or an adult with a heart condition. A recently graduated dietician leads the class. She teaches different ways to cut an onion, but is unable to answer our questions about the current popular diets (e.g., ketogenic versus intermittent fasting versus carnivore). After an hour cooking our respective meals (paella, lentil soup, and Korean chicken with rice, etc.), it was time to eat and rate. Our paella won!

Gentle Greg organized a musical variety night at a local bar for Tuesday. Several weeks ago, 15 classmates had agreed to perform, but only 5 showed up due to exam pressure. Greg had to sing every song (examples: Silver Lining by Mt. Joy, Going to California by Led Zeppelin, and Mama, You Been on My Mind by Bob Dylan). 

Exams begin with two standardized patients. The first is a 65-year-old female active smoker presenting for cardiovascular risk assessment and blood pressure management. We had to indicate all the USPSTF grade A/B recommended screenings and appropriate medications to deal with elevated blood pressure. 

The second standardized patient was a 78-year-old cheerful female presenting at the behest of her daughter who wrote a note expressing concern about her ability to drive: “She is forgetting where she parked.” I perform most of a mini mental status exam (MMSE) by asking her to recall three words, name a few objects (a pencil, watch), and serial sevens. I mistakenly forgot to ask the standard “orientation” questions (person, place, and time). Afterwards in the debrief, I learn that the patient believed that it is 1961 and the president is Richard Nixon.

[Editor: Maybe she was cheerful because Nixon was an awesome president compared to Donald Trump!]

The main exam is a 100-question multiple-choice exam on Blackboard. There were several questions on differentiating gastroesophageal reflux disease (GERD) from peptic ulcer disease (PUD), and on the workup of PUD (proton-pump inhibitor trial versus Helicobacter pylori stool antigen test). Every time a question had statin as an answer, it was always correct. A challenging question: A patient on warfarin for atrial fibrillation recently started treatment for symptoms suggestive of GERD. What medication caused an elevated INR (delayed clotting) test? (answer: Prilosec). I missed a question on what antihypertensive medication is contraindicated in gout (answer: thiazides because it decreases urate excretion).

After the exam, we have a debrief with the clerkship director. Pinterest Penelope complained about the limited time on family medicine: “We learn about all the different stress-relieving practices like mindfulness in this rotation, but we don’t have enough time to practice what you preach.” Clerkship Director: “Yeah, you’re going to be busy as a doctor, get used to it.” Gigolo Giorgio complained about the different format of the exam: “I couldn’t mark questions for review.” Father Fred: “I thought we could’ve done without a day at the nursing home, and instead spend a day with Sports Medicine. I don’t feel comfortable with a lot of fractures.”

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. For Gigolo Giorgio’s birthday, he requests to go to the gay nightclub for a night of dancing after several margaritas at his downtown apartment.

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

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We start at 7:45 am to read up on the ten patients we’ll see this morning at the clinic. 

The 37-year-old nurse (from week 25) with a large MCA stroke and amputation after subacute bacterial endocarditis (presumably from a dental procedure) is the first to arrive. Two days ago, she presented to the ED as a stroke alert. “We were driving back from physical therapy,” said her husband, “and she just seemed confused. She would ask me something that I had just answered a few minutes ago. I was frustrated and annoyed until I realized that something was amiss. I turned the car around and we headed for the emergency room.” The community hospital ED physician called a stroke alert, which initiated her ambulance transfer to the stroke center and the ensuing work-up: CT head non-contrast, CT head angiogram, CT perfusion study, MRI brain, and transesophageal echo. The headline bill could easily exceed $50,000. After six hours, she’d gotten through the first CT scans and her symptoms had resolved. I look at the imaging studies from the Epic web-link to the picture archiving and communication system (PACS, made by Sectra, a Swedish company ). The patient has no memory of the incident prior to reaching the second hospital. Great anatomy for me to go over, especially with her prior MCA infarct, but nothing acute.

The husband repeats the story when Doctor Dunker arrives. “Did she ever slur her words?” asks Dunker. “No, she just kept asking the same questions.” Doctor Dunker: “And she never had any weakness or sensory deficit on her notes. I don’t think she had a transient ischemic attack [TIA, a “mini” stroke that resolves within 24 hours]. This sounds like transient global amnesia where you are unable to remember new events [anterograde amnesia].”

If she was an “observation patient,” their private insurance might have paid only 80 percent of the hospital bills. Between the previous physical therapy bills and the new flood of charges they’re nervous. I ask if they might qualify for Medicaid. The nurse: “We would have to spin down all our assets, we’ve worked too hard. My husband worked two jobs to pay off the mortgage.” The husband: “It’s demoralizing though, we don’t know what to do.” Dunker: “I am so sorry to hear this. First, if she has another episode like this you don’t have to go to the emergency room. Call here. Of course, if she has slurred speech or weakness in the face or arm, head straight to the ED, but what she had is not a stroke.” He also informs the family about our health system’s charity programs.

After the visit, he explains to me: “I don’t understand some of these ED providers. Why did they order a full stroke work up? She didn’t have any focal neurologic deficits. I can understand getting an MRI to rule out a small infarct, but why does she need a $10,000 CT perfusion study? She is not a candidate for endovascular treatment, and is way outside the window for tPA [tissue plasminogen]. These patients break your heart.”

My next patient: A 61-year-old presents for a two-day history of pain and swelling in his left big toe that started two days ago after his daughter’s wedding. I ask how much he drank? “You know, a couple beers. I was celebrating!” What was served? “A bit of everything, fish, steak, chicken.” My diagnosis: “It looks like a gout flare to me” and explain that we will get some lab work and probably start him on high dose NSAIDs for the pain.” Doctor Dunker agrees that this is his first gout flare and we ordered a uric acid level and started him on ibuprofen. 

Our clinic holds a party to celebrate one of the doctors becoming a citizen. He went to medical school in his native Philippines and then did a U.S. residency. He explains, “There are two options for a foreign medical resident. You can go back to your home country for two years and reapply to work in the US, or you can work two years in an underserved area.”

The area continues to be “underserved” for the afternoon because I have to leave to attend a required “Bystander Awareness and Responsibility” seminar. This is organized by our university’s dean and head of the Office of Inclusion and Diversity and subtitled “A sexual and relationship violence prevention workshop for establishing a community of responsibility.”

The first activity involves the lecturer and her two full-time coordinators asking students to shout out examples of inappropriate conduct. Each is placed on an axis of socially recognized “inappropriateness”. Rape and murder are on the far right; “a bystander would recognize someone being raped is bad and act on seeing this.” We learn that a man yelling at a significant other rates lower on the agreed-inappropriate scale than rape and murder. (Every example of inappropriate conduct featured a male perpetrator.)

Next is a PowerPoint on the Pyramid of Oppression. The small sliver at the top is labeled “core offender” and is supposed by “facilitators” and “apathetic bystanders”. The foundation of the pyramid is labeled “sexism, transgenderism, strict gender roles”. “By changing these stereotypes we can stop the cycle of violence,” explains the dean. “The power dynamics in society camouflage and empower perpetrators.”

She then asks the audience to read out loud in unison statistics from the powerpoint slide:

1 in 4 women will be a victim of assault

30 percent of college couples report at least one incidence of physical aggression.

90 percent of college couples report at least one incidence of psychosocial aggression.

(No sources for these statistics were provided on the slide or elsewhere in the presentation.)

The Dean of Inclusion and Diversity adds “The vast majority of women tell the truth about rape. Only two percent are considered false stories, but this is probably an overestimate because many of those ‘false’ statistics are because of recantation. We can speculate that many of those recanted accounts were withdrawn because of fear and embarrassment.”

We then discussed several cases in groups of 8. “How does the power hierarchy impact the way you as a bystander would behave?”

Case 1: As a bystander, you walk by the surgeon lounge and notice a resident is making two medical students watch pornographic content on his phone.

Reponses:

• Pinterest Penelope: “I would never question the resident, we’d get bad evaluations!”
• Straight-Shooter Sally: “I’d provide feedback on the anonymous evaluation form.”
• Lanky Luke: “I felt that residents were just as afraid of medical students as vice versa because we write evals about them as well.”

Case 2: Several students are having a discussion in a hallway. A male patient comes out looking for ice chips. He asks for assistance from one of the students, referring to her as “honey” and slaps her backside before walking away.

Suggestions from the handout: “I never thought something like this would happen – it’s 2019!… No one is reacting… maybe it’s not that big a deal?… That student looks mortified… I’m uncomfortable with what just happened… does this have to do with gender?… This is a patient, though. Can we say anything?… What if we say something and the patient gets mad?… Should we just let this go?… If we do, will this patient continue to treat all of us and the other staff this way?… What should I do?”

Case 3: A student is asleep in a call room. Someone else (another student) goes into the room even though they know it is occupied. They don’t come out right away, and you aren’t sure that anyone else has noticed.

On Facebook, Type-A Anita comments on Joe Biden’s remarks about asking permission before hugging onstage at a campaign event: “If you think it’s appropriate to joke about making a woman uncomfortable by touching her without her permission, you’re not only out of touch, you’re also an asshole. Boy, bye.” [reference to Beyonce’s song “Sorry”]

Statistics for the week… Study: 6 hours. Sleep: 6 hours/night; Fun: 1 night. Example fun: Grilling with Lanky Luke and Sarcastic Samantha.

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

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We begin with a lecture: “How do people die?” A 55-year-old physician who runs a weekly geriatrics clinic explains why he became a geriatrician. “My father died terribly. He was in months of pain and misery during cancer treatment. At the end of his life he told me he regretted getting treatment. It is my opinion that his doctors did not present him with realistic expectations.” 

He draws a graph of function versus time on the whiteboard, each line representing a single human life. “Seven percent of people die a sudden death, meaning they are highly functioning and die out of the blue.” He draws a horizontal line high on the y-axis until it plummets when the patient dies. “These are the massive heart attacks causing cardiac arrest, the motorcycle accidents with immediate death.” He then draws a downward sloping line. “22 percent of people die of terminal illness — a long steady decline. 16 percent die of organ failure where you have ups and downs, trending down for a long time.” He continues, “So what’s left? 47 percent die of frailty. These are people who are low functioning for a long time.” In summary: “We need to think if we want to flog granny with chemotherapy and LVAD [left ventricular assist device for heart failure] just to set her up for frailty.”

His clinic reviews medications to prevent falls and unnecessary hospitalizations, evaluates prognoses for dementia and advanced chronic diseases, and discusses goals of care, including independence. “One of the most challenging discussions with the elderly is when to stop driving. Remember that the patient never voluntarily gives up driving. It signifies so much for them. A lot of time driving is essential to care for their spouse.” He emphasizes, “It is the doctor’s job to discuss when a patient should stop driving. I remember one time a patient was referred to me and he lived a few blocks down the road from me. He could barely dress himself, but was driving every day to the store. ‘Would you be okay with your son or daughter driving on the same road?’ I don’t understand how physicians are supposed to have these complex discussions with patients with all the EMR [electronic medical record] demands and time constraints, but we have to find a way.” He adds, “A good rule of thumb: if a patient cannot perform the trail-finding test on the MOCA, the patient does not have enough executive functioning and information processing capability to drive.” 

“Our clinic has a three-month back up right now. We’re still working off the backlog that develops during Thanksgiving and Christmas. The family flies in for the holidays only to find that mom has not bathed in months. They say, ‘But she sounded okay on the phone.'”

Farmer Fiona: “I agree with what he is saying about asking patients how they want to die, and that patients are vulnerable to believing best-picture prognosis. But he doesn’t say what we should do to manage unfortunate events. Should patients not undergo catheterization after a heart attack? Not get amputated after a gangrenous diabetic infection? Maybe he wants us to tell patients to keep smoking so they die of a massive heart attack, instead of the long fragility of dementia or pancreatic cancer?” Southern Steve: “Is it worth risking getting dementia to live to 100?”

After lecture, Fiona and I drive 10 minutes to the hospice clinic where we get a tour from a 56-year-old volunteer office manager. He explains: “Hospice sprang up as community volunteer organizations. We used to be able to take patients on fishing trips, meals, shopping. We can’t do that anymore because of the liability of driving patients and all the paperwork involved with insurance. The volunteer tradition is going away, but five percent of a hospice workforce must still be volunteer to qualify for Medicare reimbursement.”

I follow a 48-year-old hospice nurse around the city for three home visits. My first patient (a 35-minute drive away): is an 89-year-old end-stage dementia patient. Before we go in, the nurse explains that family members are “really struggling giving medications (oxycodone and benzodiazepines) because they are afraid of killing her.” She explains to the son, daughter-in-law, two granddaughters, and great-grandson that the doses of pain medications are so low she will be fine: “She needs these medications. We don’t want her to suffer.”

[Editor: The U.S. has 5 percent of the world’s population and consumes 80 percent of the prescription opioids.]

After spending 10 minutes at bedside, including a short prayer led by the hospice chaplain, our patient is agitated. We go to an empty bedroom for a family meeting. Everyone starts crying. The son: “I am not ready to let her go. I freak out about giving her medications if they are going to hasten her death.” Hospice nurse: “She is ready to go. You have to accept that and prepare yourself.”

Our next patient with advanced COPD and dementia lives in an upscale continuing care retirement community home. She has a 24-hour home aide who has dressed her in stylish clothing, arranged her hair, and applied makeup. She takes shallow breaths as she stares blankly into space, not acknowledging the two strangers in her apartment. We talk with the 38-year-old home health aide, a relative of family friends who has been taking care of her for two months. The hospice nurse: “You can tell she is going to die soon. She’s ready. It’ll be tonight I think.” She calls the family’s relatives to come to the apartment. (Our patient died three hours later, with her family at bedside.)

Our last stop: an 86-year-old bedbound patient with congestive heart failure living in a beautiful six-bedroom house. A professional 28-year-old home health aide takes care of him (and the bulldog who greets us at the door) five days per week and a neighbor’s failure-to-launch 34-year-old son handles the weekends. We turn him over to look for bedsores; the home aide has done a very good job. When was the last time you pooped? The aide responds that it has been at least six days. The nurse looks at me. Enema time. We roll him over to one side, and perform an enema. He has so much impacted stool we do two. The enema took about twenty minutes. The nurse was surprised that I helped throughout the enema. “Most doctors walk out the door as soon as the thought of an enema pops up.”

I drive back to the hospice clinic for afternoon handoff with Farmer Fiona. Nurses and the palliative care physician are talking about overnight drama between the hospitalist service and palliative care team regarding a terminal cancer patient experiencing poorly controlled pain. “The family did everything right and called the hospice instead of going to the ED. But this hospice does not have flex weekend home visits.” The family brought the patient to the ED, and the medicine service requested the palliative team admit the patient. The palliative care physician: “I told them that we are not admitting the patient. This is a disposition issue that their social workers can manage. We are not in-charge of every hospice patient,” she noted. “We’d be happy to consult on the patient in the morning to provide pain control recommendations, but we are not admitting to our unit. We have limited resources.” (Last week on their service, we sat idle for half the time, sipping specialized coffee drinks made by a volunteer and discussing must-read medical books..)

Thursday morning is a normal day with Doctor Dunker at my family medicine clinic. We had a monthly potluck office lunch featuring homemade apple turnovers. Staffers are comparing their role-specific Bingo cards. For example, Doctor Dunker has a square: “Patient asks for antibiotics before patient is seen by doctor.” The office secretary: “Patient no shows appointment within 24 hours of scheduling.”

I depart after lunch for an afternoon at the travel clinic. The travel clinic, staffed by an infectious disease doctor, is meant as a community resource for individuals traveling for extended periods of time to remote destinations, e.g., six-month mission in Africa or the Amazon. Instead, all four of our patients are going on cruises with limited exposure to dangerous disease beyond an afternoon in Cartagena, Colombia. There is no attempt to hide from the patients that we are primarily looking up information on the CDC web site.

[Editor: Cartagena was where agents accompanying President Obama to the Summit of the Americas used government credit cards for an epic party. See “US Secret Service Cartagena scandal ‘involved 20 women'” (BBC).]

Friday afternoon, we have a class meeting about prevention in primary care. The lecturer, a retired hippie family doctor, discusses the “Pay-for-Performance” era. He reviews a “landmark study” finding that the highest performing practices according to metrics in the UK had no change in patient outcomes compared to poor performing practices. “Despite this evidence, we will see more and more oversight by administration evaluating performance metrics. We’ll soon be telling patients, ‘I need you to get a mammogram, flu shot, etc. because it will improve my clinic performance.'”

[Editor: We learned the same thing in our data-driven medicine class at Harvard Medical School. Except for generating headlines, preventive medicine is of limited value. Popular screening tests, such as mammograms and pap smears, generate so many false positives that patients on balance may be worse off. Flu shots for adults are only weakly correlated with being diagnosed with flu.]

He continued: “One challenge for performance metrics is they address challenges of the past or are out of touch with reality. For example, hospitals get graded on how quickly we start antibiotics for sepsis and pneumonia — the proportion started within 8 hours. This metric is based on studies in the 1990s which showed early administration improved outcomes in sepsis. However, this was on a totally different patient population and different bugs because this was in a day before the pneumonia vaccine existed. There is no evidence administration within 8 hours is beneficial, and instead might cause unnecessary antibiotic administration. You all see that so much, antibiotics are started in the ED for a few hours and then discontinued by medicine service the next day.”

Statistics for the week… Study: 7 hours. Sleep: 7 hours/night; Fun: 1 night. Lanky Luke, Sarcastic Samantha, Mischievous Mary, Geezer George, Buff Bri, Jane, and I attend a free concert downtown.

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

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Monday morning: 84-year-old “T-Bone” car accident victim for a hospital follow up. He was admitted to the hospital for seven days with multiple rib fractures and a wrist fracture. A CT of the abdomen showed, in addition to the acute injuries, a dilated common bile duct with the radiologist report stating, “cannot rule out malignancy versus cholelithiasis [gallstones]”. We explain to him the possibilities, and that to determine this we would need to order an endoscopic retrograde cholangiopancreaticography, a procedure in which a scope is placed down the esophagus into the small intestine and injects contrast into the biliary system. “Doc, I was just in the hospital for a week, it took everything out of me. I dont have the strength to get another anesthesia procedure. I’ve had a good life.” We agree with him, and decide to monitor with blood work.

I am beginning to work on the worksheet that we must complete before the end of our six-week rotation. Having asked the three nurses to grab me if anyone needs shots, I get several intramuscular injections checked off by giving flu shots and quadracel vaccinations to children. I also need to perform five EKGs (electrocardiograms). I see a fit 38-year-old nurse who works in the Cardiac Care Unit (CCU) and has experienced feeling faint three times within the last month. Her nursing colleagues hooked her up to telemetry, which showed “an arrhythmia”. I hook up our clinic’s EKG machine’s leads to her, but nothing happens. The three nurses all come in to help troubleshoot. We cannot fix it so we decide to have her return in a few days.

Wednesday morning, Farmer Fiona and I head into the depths of the hospital for an afternoon with occupational medicine (“OccuMed”), a clinic that treats hospital employees for work-related issues. The 32-year-old physician trained with the military before leaving to work in civilian practice. The five patients on his schedule were all no-shows, so we got a 2.5-hour sales pitch regarding the great lifestyle of an OccuMed doctor: “We have no call, our day is like a dermatologist’s.”

His team is responsible for safety protocols at the hospital. He explains the airborne precaution protocol. “OSHA  mandates a standardized nine-question questionnaire with any ‘Yes’ responses requiring a formal physical by occupational medicine. A few years ago we used a slightly different form, and we developed an in-house scoring system to determine need for a physical. Our system was actually more restrictive, requiring almost every employee to get a physical, plus we also do annual physicals on clinical workers. The higher-ups couldn’t understand why we needed to use the OSHA-approved form. What we were doing was actually illegal due to the paperwork discrepancy.” A big smile took over his face: “That’s the beauty of OccuMed. We understand the intersection between medicine, administration, and law. And it’s only getting more complex. We’re the only ones who can do this.”

Lanky Luke, Mischievous Mary, Geezer George, and I head to an impromptu Wednesday beers and burgers night. Geezer George describes the tension between the employee trying to get a work-related pay out and the OccuMed doctor working on behalf of the hospital trying to minimize the problem: “The doctor asked, ‘Could you please bend over and touch your toes.’ The patient responds, “I can’t, it hurts to move my back.’ ‘I know, but just try and touch your toes.’ ‘Okay,’ it’s going to hurt’ As he bends over and attempts to touch his toes, the physician comments, ‘So you can bend over.’ ‘Yes, but it hurts.’ He ended up getting disability.”

Luke recounts his week on inpatient pediatrics. He explains: “We admitted a six-month old with RSV [“respiratory syncytial virus,” a common illness at this age]. The baby presented to an outside emergency room where she was given an intraosseous catheter access [“IO”, a radical drill-through-the-bone procedure with significant risks that was unnecessary for this patient] and medevaced to our tertiary center. The baby was totally fine on arrival. Our attending admitted the patient overnight because the baby was helicoptered in and said ‘The patient has an IO so I guess we should use it.'” Samantha, the PA wife, recounted a similar experience: “We had a patient with chest pain — no troponin or EKG changes — medevaced to our hospital. My attending commented that he would never have been admitted if he’d come into the ED, but he was helicoptered in from six hours away. We let him stay the night under observation.”

Thursday: I spend 30 minutes talking with a fit 64-year-old who had bilateral total hip arthroplasties (replacements) over a decade earlier. After a tooth extraction, he was admitted for a 5-day ICU admission for sepsis in both of these artificial joints. He underwent two surgeries and a 50-day rehab stay. He is now doing a 3-week antibiotic holiday to confirm no infection before a revision. He is back home, but is not allowed any weight bearing on either leg.

The next clinic patient is a 35-year-old female, BMI 32, with a history of depression and polysubstance use disorder (alcohol, benzodiazepines, and cocaine) presenting as a new patient due to worsening shortness of breath. She explains she drinks a few beers on the weekend, but has been sober from other drugs for the past three years. She is also very upfront about being incarcerated for the past three years: “I was selling cocaine and meth.” My attending: “I always find it ironic when a drug user includes incarceration years as part of their sobriety time.” We order an echo, but strongly suspect she is drinking causing an alcohol-induced cardiomyopathy. We discontinue her seroquel, which might help her lose some weight, order an echo, and instruct her to stop drinking alcohol.

We are required to attend an Alcoholic Anonymous (“AA”) meeting as part of this rotation.  Wildflower Willow and I select a Thursday evening meeting through the AA online portal (there are more than 10 within a 20-mile radius every night). The leader asks the 35 attendees if anyone new would like to introduce themselves. Older people tend to be sober and say “I am an alcoholic” while the members who are our age are more likely to be active users and say “I am alcoholic and an addict”. Willow: “I didn’t like it, it felt like we were sent to the zoo to learn from the freaks firsthand.”

Friday morning: “Medicine” grand rounds on gastrointestinal bleeding at the hospital, then head to the clinic around 9:00 am. I burn several actinic keratosis  (“AK”, a common precancerous skin lesion) off with cryotherapy. Doctor Dunker lets me do two punch biopsies on a patient with numerous nevi (moles) on his back. I grab supplies, including local anesthesia, suture, drapes, needle driver, and forceps. The next step is to draw lidocaine and epinephrine into a syringe and inject to anesthetize the nevi sites until a “wheal” forms.

Doctor Dunker sees that I am comfortable getting the supplies, so he lets me do an excisional biopsy on a later patient whose previous punch biopsy pathology results showed a squamous cell carcinoma in situ, but with “positive margins” (i.e., the cylindrical punch biopsy did not remove the entire lesion). Steps: acquire supplies, prep the site with iodine, use a sterile marker to outline a 1cm margin around the lesion, incise with scalpel until reached subcutaneous fat, cut tissue with scissors, place into tissue container, suture wound close. Doctor Dunker: “Great job. Haven’t seen anyone hand-tie in quite awhile.” (As opposed to “instrument tying” using a forceps and needle driver.) This was my first time doing surgery on a conscious patient.

The last patient of the day: 47-year-old overweight female on birth control presenting for an annual wellness visit and mentions foot pain when walking. The ankle appears swollen and slightly inflamed. Although the patient does not report any worsening shortness of breath, our concern is she may have a deep venous thrombosis of the lower extremity (“DVT”, a clot in the leg, which can throw small chunks into circulation until they reach the lung). Alternatively, it could just be a sore muscle. Following the standard protocols, which are heavily biased toward defensive medicine, Doctor Dunker decides to send the patient to the ED. “Every doc will get burned by a PE [pulmonary embolism]. I wonder how many CTs it takes to diagnose one PE? How many CTs to save one life for a PE?”  (After a no-doubt multi-thousand dollar bill to the insurance company, and a whopping deductible cost for this rare privately insured patient, the hospital determines that there is no DVT.)

Statistics for the week… Study: 8 hours. Sleep: 9 hours/night; Fun: 1 night.

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

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Week 2 on family medicine rotation. Monday morning begins with a one-hour lecture by a 53-year-old talkative palliative care specialist (“helping patients learn how to live with serious illnesses”).

Palliative care was recognized as a speciality by the American Medical Association in 2008. “The profession has exploded since insurance realized that palliative care consultations save money. The problem is we don’t have enough fellowships to meet the demand.”  She would like her colleagues to be involved with CHF, COPD, cancer treatment, dialysis, and dementia when a patient has a life expectancy of less than 18 months. She adds, “We are far behind Canada with integration of palliative care into medical management. For example, palliative care specialists are typically at every Canadian dialysis and heart failure clinic.” Why is the U.S. lagging? “Political motivation,” she responded. “Palliative care became known as the ‘Death Squad’ created by ObamaCare.”

In the old days, every physician was considered qualified to educate patients and families about the logistics and prognostics of different care options, e.g., whether to agree to surgery or proceed with intubation in a terminal disease. Now the conversation gets punted to a credentialed separate specialty: “We also investigate the reasoning behind a family’s decision, we sometimes just listen but we can also use evidence-based methods to guide a patient to a more informed decision,” she explained. “For example, a 27-year-old polysubstance user got into a car crash. The ICU team doesn’t want to intubate because they fear it is unlikely the patient will ever be extubated. The mother wants the whole nine yards. We came in to talk to the family for goals of care and learned that the mother’s insistence was driven by a fear that the son was going to Hell. We coordinated chaplain services and eventually the mother agreed that it was time to let the son pass away.” (Hospitals have a substantial financial incentive to bring in palliative care specialists, who can bill more per hour than an internal medicine (hospitalist) physician.)

Roughly 80 percent of the time, she is discouraging patients from opting for expensive yet low-value procedures. In some cases, however, it is the palliative care doctor who pushes for a procedure: “A 38-year-old male had multiple life-threatening injuries including spinal cord compression and blunt abdominal trauma leading to a partial colectomy and colostomy after an industrial work accident. He was in constant pain. His neurosurgeon recommended against spinal cord decompression due to the high risks of surgery. We recommended he undergo it even though it would likely worsen life expectancy because the family and patient could not bear to see him in so much pain.”

Farmer Fiona and I happen to be assigned to palliative care for Monday, so after the lecture we head over with the attending to the palliative care team room. Each of us sees two patients. I sit in on a family meeting concerning a heavily sedated 69-year-old male with COPD and congestive heart failure in the ICU. The family has been debating for three weeks whether to stop the pacemaker that is keeping the patient alive. The wife is tearful, but says it is what he would want. “He wouldn’t want to live like this in the hospital.”

[Editor: It is always the spouse who wants to pull the plug, citing a never-committed-to-writing desire to be dead rather than sick, and the kids who want to keep a parent alive. Keep that in mind when setting up a health care proxy.]

After the meeting, we call the cardiology service. Some providers and device manufacturer representatives are hesitant about stopping the life-saving device. “One of the cardiologists on the service refuses to do these types of procedures,” says the attending, “but the one on tomorrow understands.” The manufacturer rep pushed back, but eventually relented after discussion with the cardiologist. We scheduled the shut down for the next day. This would allow the family from out of town to be present for the patient’s final hours. 

I join the attending for a new patient in the neurotrauma ICU. The 67-year-old male recently had a car accident and was coded for 10 minutes until a pulse came back. We don’t know anything about neurosurgery and haven’t talked to the patient’s neurosurgeons, but we have read some notes in Epic and supposedly have expertise in how to break bad news to patients. We had a (necessarily) vague conversation that might have helped the family formulate some questions for the neurosurgery team and most definitely helped the hospital collect revenue from Medicare.

Tuesday: family medicine clinic. The first patient is a 43-year-old father of two and aircraft mechanic for UPS presenting for an annual checkup. We discuss indications for statins given his 10-year cardiovascular risk above 7.5 percent. We prescribe Lipitor and counsel regarding smoking cessation. He mentions job-related back pain. Doctor Dunker performs a brief strain/counter-strain OMT technique. “What I really need is a massage from my wife.” Doctor Dunker jokes:,”Want me to write a doctor’s note?”

During annual visits, we evaluate USPSTF (United States Preventive Services Task Force, a panel of experts appointed by the Department of Health and Human Services) Grade A/B screenings and CDC vaccine recommendations. We often have a discussion about the new shingles vaccine, Shingrix. Our office does not carry the vaccine, which costs $100 at a local pharmacy and Medicare Part A or Part B do not cover this. Patients on whom taxpayers are spending $10,000 or more annually balk at the idea of paying $100 dollars to cut their risk of getting shingles from 33 percent to about 1 percent.

Doctor Dunker recounts several patients that have permanent life-altering complications from shingles, namely postherpetic neuralgia. “I had a retired nurse commit suicide because of the intense pain. It is just like trigeminal neuralgia.” (Also known as the “suicide disease”, trigeminal neuralgia is a chronic pain disorder with recurrent episodes of intense, unexpected jolts of pain on one side of the face that last for a few seconds.)

I sit in on a visit for a 68-year-old female active smoker with congestive heart failure (CHF) who does not understand her disease. She arrives with a “care coordinator,” a nurse with extra training whose job is to prevent hospital readmissions and reduce the chance that the hospital will get dinged by Medicare under the Readmissions Reduction Program (RRP). She has had two CHF exacerbations requiring readmission due to a lack of understanding of her medications and when she should take her “fluid” pill to avoid becoming volume-overloaded. I use her chest x-ray from the most recent admission to explain why she’s becoming short of breath and  say that we will likely need to increase her metoprolol dose to control atrial fibrillation and keep her heart rate below 110 beats per minute. Her INR (international normalized rate, a measure of blood clotting when on Coumadin) from today’s in-house blood draw was increased. I told her that the hospital’s latest amiodarone prescription may be responsible. I feel like I am getting the hang of outpatient medicine!

Thursday afternoon: playing around with Epic and notice an InBasket message, which I hadn’t realized we have access to. Who would send me something in this? It is a request from Doctor Dunker that I look up ectopic kidney (kidney located in the pelvis). I do research on UpToDate.com and present findings to Doctor Dunker to help him prepare for a meeting with a family and their newborn. I explain the main considerations in management of ectopic kidney are: (1) risk of hydroureter/hydronephrosis,  (2) association with other congenital anomalies, and (3) increased risk of urinary tract infections

Doctor Dunker takes responsibility for his patients, a contrast to the hospital’s poor continuity of care. For example, on Friday morning, we see a 72-year-old female who was admitted to the hospital the previous week for a GI bleed. The patient was stabilized on IV fluids and 2 prbc. The EGD showed no abnormalities, but because the patient stabilized a colonoscopy was not performed. She now has to wait several weeks for an elective colonoscopy. After several thousand dollars in hospital bills, still no answer. No ownership.

[Editor: It’s not all bad. Via the above incident, the hospital obtained “ownership” of several thousand tax dollars via Medicare!]

Statistics for the week… Study: 8 hours. Sleep: 9 hours/night; Fun: 1 night. Twelve classmates drive 30-minutes outside town to a new, dog-friendly brewery.

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

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We pick up our hero’s story in January 2019, halfway through Year 3.

Orientation begins at 7:00 am. Our clerkship director, a 58-year-old family doctor, explains that we are expected to write at least two notes per day at our assigned clinic. “Get used to the SmartPhrases [canned templates within Epic, with fields such as patient age ready to be auto-filled] your team uses. Half the note is just for billing, which makes it frustrating to find information even in my own notes, let alone others’. But we have to work with it.”

He describes the distinction between family medicine and general practice. “General practitioner developed bad connotations because it was basically a physician who did not complete a residency. You were considered a general practitioner (GP) in your third year of medical school. My dad delivered babies by himself as a fourth-year medical student. Family Medicine fought back against this confusion by becoming the first society to require a board examination.”

The orientation was followed by a lecture on geriatric polypharmacy (drug interactions and the consequences of our pharma-happy medical system). A geriatrician (family doctor with geriatrics fellowship) in her 50s: “More than 12 percent of the US population is over 65. An estimated 50 percent of these folks take more than five medications. Polypharmacy has serious consequences; 30 percent of hospital admissions are estimated to be from adverse drug effects.” Why aren’t the hazards of over-pharma better known? “There are a lot of studies looking for a primary discharge diagnosis of ‘adverse drug reaction’ as an ICD-10 code. They will miss a situation in which the adverse drug reaction caused the primary problem, e.g., a patient falls from too many anti-hypertensives and breaks her hip.” 

She describes Beers Criteria, a list of potentially inappropriate medications in the elderly that can lead to falls, fractures, gastrointestinal bleeds, delirium, and overall increased risk of death. “We’re trying to get away from the lady that takes a few Xanax every night for 40 years,” she exclaimed. She described analgesia in the elderly. “Too often we avoid giving opioids because of the stigma, but they are frankly one of the best options to manage pain in the elderly. The alternative of NSAIDs [e.g., Advil] causes serious GI bleeds and destroys the kidneys.”

She added, “When you get a few years under your belts, you’ll start to notice pharmaceutical tricks. When a commonly used drug is about to go generic, the company will conduct a clinical trial with a dose that cannot be obtained from a combination of pills already on the market. For example, Aricept [donepezil], medication used in Alzheimer’s dementia despite minimal clinical benefit]  comes in 10 mg and 20 mg. Before the patent expired, Pfizer conducted a trial at 22 mg. It didn’t work, but if it had, they would’ve sought FDA approval for the 22 mg level, and then insurance would have paid only for the FDA-approved dose, otherwise it would be an off-label [uninsured] use.  Same thing happened with Claritin.” She concluded: “Learn the rules, so that you may break them properly.” She requires us to conduct a polypharmacy review of an elderly patient during our rotation.

[Editor: See a March 11, 2001 New York Times story on Schering-Plough keeping Claritin from becoming an inexpensive generic via dosage tweaking leading to patent extensions: “The Claritin Effect; Prescription for Profit”.]

Farmer Fiona, a 26-year-old from rural America who is interested in rural family medicine, and I are paired for our weekly nursing home days. Fiona texts the attending who tells us to meet him at the assigned nursing home at 1:00 pm. I rush through lunch at the gas station burrito shop, but need not have hurried since the doctor does not arrive until 1:30 pm. He assigns us two patients each, one admission and one follow-up. After 45 minutes, we reunite with the attending and present our patients in a conference room. My 65-year-old patient has been in and out of the rehab facility twice after pancreatitis hospitalization complicated by an abscess formation requiring laparotomy (cut open abdomen). He is experiencing worsening nausea two days after discharge from the hospital. He has no peritoneal signs (inflammation of abdominal wall), or systemic signs of infection (fever, tachycardia). We prescribe Zofran and plan to re-evaluate him the next day for possible transfer to the hospital for imaging. We then round on 5 patients in skilled nursing, and 5 patients in the long-term care section of the assisted living complex.

Tuesday morning I drive 45 minutes into the countryside to a family medicine clinic that will be my primary home for six weeks. Work starts at 8:30 am, so I get more sleep than during the surgery and internal medicine rotations. The office has three physicians, one of whom works 2.5 days per week and spends the rest of the time with her children. It isn’t difficult to craft a work-life balance when a nice house near the clinic costs $250,000 and a full-time doc is earning $220,000/year. I will be working only with the two full-time physicians. We are able to perform lab draws (in-house A1C, CMP) and electrocardiograms, but no onsite x-ray.

Doctor Dunker is a 41-year-old member of a traditional Anabaptist group. He has seven home-schooled children, a beard that flows down to mid-chest, and dresses like an Amish farmer. He comes in at 8:30 am on the dot wearing a pressed white shirt with baggy black pants and a black vest. He expects the nurse (also in traditional garb, including bonnet) to have prepped his first patient and will put his black hat on the desk, don a white coat, and go into the exam room within a minute of arrival. Jane and I won’t be able to complain about working hard in medical school; Doctor Dunker had two young children to care for during his medical education.

He cares for a village, about 3400 patients spanning several generations of families, twice as many patients as the other full-time attending in the practice. About half are from his traditional community, many driving two hours from the rural area in which he formerly practiced, and some making all-day drives from other states. “They just keep having children, and I can’t say no.” He has learned to have low expectations for M3s: “Things are crazy around here, I actually requested to not have a medical student this block. I know this isn’t your fault. Today, you’ll just follow me. We’ll figure a way to make it work. I still want you to get comfortable with doing great outpatient encounters.  I just can’t get behind on my patients because I have to leave on time.”

The typical day has acute visits and medication follow-up visits scheduled in 15-minute blocks while new patients and annual visits are scheduled for 30 minutes. We are supposed to take a lunch break from 12:00 to 1:30 pm (oftentimes interrupted by 1 or 2 fill-in appointments) and are done at 5:00 pm. On two days per week, Doctor Dunker stays late and sees patients until 7:00 pm.

The first visit is a joint annual check up for an Anabaptist couple in their 70s. We start with a routine health check and filling out a Medicare annual form ($35 in extra revenue) that asks how long it takes the patient to “get up and go” (should be under 20 seconds to rise from sitting, walk 10 feet, turn around and sit back down), domestic violence screening, and dementia screening test with Mini-Mental Status Exam (MMSE, including a three-word recall and drawing a clock). The wife asks: “By the way, one more question. Our granddaughter is pregnant and needs a note to take five-minute breaks at Walmart when she gets short of breath. Could you do that?” He was silent for a second. “I cannot confirm or deny that she is a patient of mine or her situation.” The couple laughed, “Oh, Doc. We know she is pregnant, she told us, and we’re ecstatic. Her boyfriend, hopefully fiance, is a great guy and all about her. And by the way, you’re a terrible liar!” Doc Dunker: “If she is a patient, I will reach out to her.” As the old couple leaves, they comment approvingly on the Christian artwork.

We see a 12-year-old girl for eczema. Last visit, Doctor Dunker had ordered a compounded steroid cream. However, Medicaid had rejected the order, even though it is a generic medication. “This can be so frustrating. They reject what I order, but won’t offer an alternative.” He adds, “Finding a medication that Medicaid will pay for is like whack-a-mole.”

Doctor Dunker: “The next patient is quite interesting. Interview the patient when she arrives while I see the roomed patient.” A 37-year-old female former nurse, local but not Anabaptist, presents for a one-month follow-up after discharge from a stroke rehab program. After a routine dental procedure and despite being generally healthy, she contracted subacute bacterial endocarditis (heart valve infection). The infected valve threw clots into her arteries, one to her middle cerebral artery causing a stroke, and one to her left leg causing gangrenous necrosis. Her left leg was amputated above the knee. She was in rehab for a month, with follow-up physical and occupational therapy appointments.

The patient is way out of my league. I don’t know what questions to ask about the post-stroke recovery process. Fortunately, Doctor Dunker knocks on the door. The patient and her husband brighten, “Doc look at this. She attaches her prosthesis to the left lower extremity stump, and walks to the door. “Oh my God. Wait here.” He calls the nurses and front desk staff. “Everyone come here and watch.” People cheer as she walks down the hall.

When the commotion subsides, she explains her challenges going forward. “Insurance won’t pay for any more PT or OT [physical or occupational therapy]. My husband and I have worked too hard to go for the Medicaid spend-down, but we just can’t afford these $150 sessions out of pocket. I wish we had known what we know now. We had only 10 sessions for PT and OT. If we scheduled them back-to-back, they count as one, but we scheduled the first few at separate times so it counted for two seperate uses.” Doc Dunker: “Let me see what I can do.” He calls our care coordinator, who gets her another 10 PT and OT sessions from charity care.

[Editor: when a hospital reports “charity care”, it is at the fictitious list prices that are often 10X what an insurance company would pay. “How Much Uncompensated Care do Doctors Provide?” (NBER, November 2007) concluded that “uncompensated care amounts to only 0.8% of revenues” and that physicians actually were “earning more on uninsured patients than on insured patients with comparable treatments.”]

The next patient is a 69-year-old male, accompanied by his daughter, for worsening hallucinations associated with Lewy body dementia (LBD). LBD is characterized by early vivid visual hallucinations followed by progressive decline in cognitive function. He called 911 at 2:00 am because he thought his wife had stopped breathing (in fact, she passed away 10 years earlier). This is the fourth time he has called 911 for a hallucination. He describes how he sometimes sees large beetles (“size of my hand”) crawling on him at night. My attending describes this phenomenon where objects appear bigger or smaller than reality as Lilliputian, dubbed the “Alice in Wonderland” syndrome. The patient is quiet throughout the interview, clearly embarrassed about his behavior. Afterwards, we just sit in the room for a few seconds. “So sad, his body is fit but his mind is failing him. He knows right now he has a problem. This can be the most devastating period of the dementia.” (Robin Williams who committed suicide at 63 suffered from the “terror” of LBD.)

[Editor: Williams was also being pursued by two alimony plaintiffs. New York Daily News: “Paying out over $30 million

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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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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.)

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

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