Philip Greenspun’s Weblog

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

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

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

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