Philip Greenspun’s Weblog

Work starts at 8:00 am at an outpatient pediatric clinic that is a one-hour drive from the hospital. I’m the only student in the clinic. I meet the three attendings, one advanced care provider (“ACP,” typically a PA or NP), and lactation consultant) before the first scheduled office visits at 8:30 am. Two of the attendings are hot off the press, having finished their residencies a year ago. Momma Mabel had a baby in December and is back after three months off [Editor: fully paid thanks to the extra work put in by the childless.]. Her husband is a stay-at-home dad who brings the baby in during lunch. Mercedes Mike, the other new attending who drives a new SLC Roadster, and Busy Belle, a divorced pediatrician in her 50s who is booked weeks out except for two unscheduled daily sick slots. 

They have fifteen 15-minute well-child-checks (“WCC”) scheduled each day, thirteen 10-minute scheduled sick visits, and two open 10-minute sick-visit slots at the end of the day. A complicated patient, e.g., chronic headache, may be allocated two 10-minute slots. Five minutes out of the 15 are allotted for rooming. The nurse will get vitals while the physician writes up notes from the previous encounter. The physician then has either 5 or 10 minutes to see the patient without falling behind. I go in with Mabel for a 4-month-old WCC. Mabel invites me to listen to the patient’s heart and I hear an early systolic murmur. When I tell Mabel about that, after the encounter, she says “Yep, good job. That’s called a Still’s murmur. It classically is described as having a musical quality. I didn’t tell the parents because it is a benign murmur of childhood.” Mabel pumps during the one-hour lunch break as I head over to the other side of the office for lunch with Busy Belle.

Belle explains the different pay structures for primary care. Some health systems use a flat salary. “You are required to see a minimum number of patients.” Many health systems are transitioning to a relative value unit (RVU) reimbursement structure. Mercedes Mike stops by and adds: “I  considered working for another system that is completely based on RVUs. I’d get paid more per patient, but if I decided to go on vacation for two, I would get nothing. I felt this was a little nerve-wracking for me just starting out with a young family.” Another factor emerging is scorecard evaluation. “We get evaluated based upon peer performance across selected metrics, e.g., smoking cessation, weight loss.”

I shadow Belle for the remainder of the day and we’re done with patients at 4:30 and out the door at 5.

Tuesday I graduate from mere shadowing and begin to interview patients alone prior to the attending coming in. My first  interview is with the mother of a 2-year-old presenting for a two-day history of sore throat, fever, and runny nose.The kid just started daycare, and the parents took an ear temperature at 100 degrees, which means she’s technically afebrile because fever starts at 100.4. I complete a physical exam before presenting the findings to Mabel while she fills out an Epic SmartText template. Students are allowed to write notes for surgery, but not for pediatrics due to concerns about insurance reimbursement. We then both go into the room. Either I got the history wrong or the mother has changed her story. The sore throat began three days ago, not two and nasal saline rinse has been used, contradicting my report of no medications. Afterwards, Mabel completes her own physical. We send them home and recommend symptomatic management with Tylenol and ibuprofen if needed.

Our next four patients come in with sniffles or sore throat. I can’t find signs of bacterial infection. “What is your assessment?” asks Mabel.  “She has a viral pharyngitis that can be managed symptomatically. Let’s tell them to keep hydrated and make sure there are 3 or 4 wet diapers per day. Return in case of fever.” In the afternoon, I see a 6-month-old with conjunctivitis, bilateral otitis media, and pharyngitis caused by a suspected adenovirus infection. Mabel: “Notice the difference? Treatment is symptomatic, but these kids can get really sick. Tell me the serious complications of adenovirus?” She goes into the next patient while I look at UpToDate. I report that the main complication of adenovirus is pneumonia. Fifteen percent of childhood pneumonias are caused by adenovirus and myocarditis (a rare heart infection) is usually caused by certain strains of adenovirus. Finally, I report an outbreak of serotype 7 that caused a serious outbreak in 2014 with 136 (69 percent) of 198 persons with adenovirus-positive respiratory tract specimens were hospitalized, out of which 18 percent required mechanical ventilation, and 5 patients died (“Human Adenovirus Associated with Severe Respiratory Infection, Oregon, USA, 2013-2014”, Emerg Infect Dis. 2016)

After I finish a 17 year-old WCC and sports physical, my attending grabs me to come take a listen to 9-month-old twins with bronchiolitis. “Could my medical student listen?” she asks the parents. These are the sickest patients I’ve seen today and show classic signs of adenovirus: conjunctivitis, runny nose, cough and pharyngitis. I listen to their lungs and hear inspiratory crackles with an expiratory wheeze. There are no signs of dehydration, such as lack of tears while crying, poor capillary refill, poor urine output. They are not in respiratory distress, e.g., nose flaring, intercostal retractions, abdominal muscle use. We sent the family home with instructions regarding what would merit a follow-up visit.

I’m learning that most of a pediatrician’s job is educating parents on the basics: when to brush teeth, how often to breastfeed, what car seat should the child be in, how much should the baby drink, when to stop using the bottle. The format of a well child check is standardized for each age. Despite the hundreds of millions of dollars spent to install Epic, it doesn’t default to the practice’s preferred form for, e.g., a 10-year-old, when a 10-year-old patient is being seen. The efficient physician populates a custom-made SmartText for a 10 year old, and then fills out certain milestones that were filled out by the parents on paper.

Statistics for the week… Study: 5 hours. Sleep: 8 hours/night; Fun: 1 night. Example fun: best friend from college visits this weekend. He is an M3 at a different school who has already been on rotations for six months: “Third year sucks. Physicians claim that they remember third year as the best. Bullshit. It is mostly waiting around doing nothing, and yet you have no free time.” He adds: “Scary to think this is all the training we have in some areas. For example, if you don’t want to be a surgeon, you will be a practicing physician with only a few weeks of surgery experience. It wouldn’t surprise me if some physicians don’t even know how to start an IV anymore.” He is looking forward to psychiatry: “You talk to each patient for 30 minutes, chart a note during the interview. Pay for psychiatrists grew 15 percent last year. If this continues for 5 years, a psychiatrist will get paid as much as an orthopedist and get out every day at 2:00 pm.”

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

Sunday and Monday with the trauma service team. They don’t expect much from students this week because they know that we’re thinking about the exams that start on Tuesday. Ted, my chief, tells instructs me, “You can go study in the student lounge. We’ll let you know if anything interesting pops up.”

There are only 183 UWorld surgery questions. It takes about five minutes per question, each of which has five possible answers, to pick an answer and then read the explanations associated with each possible answer. I have studied all but 44. M4s and previous clases recommended getting through the Internal Medicine gastrointestinal and pulmonology questions as well because they all overlap with the Surgery SHELF exam. Surgeon Sally and Christian Charlie both finished the 113 GI and 123 pulmonology questions on top of the surgery questions.

In the ED, we have a skinny 26-year-old patient who was in a head-on collision. He is in no apparent distress, with some minor hip pain that is well controlled on 5 micrograms fentanyl. An x-ray shows a femoral head (top of femur) fracture extending into the acetabulum (hip bone). Was he drinking? He replies in a muted, monotone voice: “No.” Use any drugs? “I’ve used meth and heroin in the past. I wasn’t using anything.” Nurses keep telling him how amazing it is he came out with only minor injuries after a 65 mph crash, but he doesn’t perk up.

What do you do for a living? “I worked in a mechanic shop, but I’m between jobs. I lost my job two weeks ago.” He shrugs. “It’s whatever.” Ted joins me in the ED, recognizes the last name, and we admit the patient to our service (“trauma”), and consult orthopaedic trauma service. Our job is mostly coordination with more specialized services.

We are placing orders in the ED when the patient’s father and mother arrive. The father is a well-respected doctor in the hospital. Out in the hallway, the parents report that their sonhas been diagnosed with schizophrenia and major depressive disorder, but refuses to seek help for the past two years. “He’ll live with us for a few weeks, then we won’t see him for moths. He currently lives out of his car.. He’ll keep a job for a few weeks to get money for drugs, then quit.” We go back in and ask about his psychiatric history. He admits that he purposefully drove across the yellow lines into traffic. (The mother and back-seat child in the other car were not seriously injured and had been taken to a hospital without Level 1 Trauma certification.)

We place him on suicide precautions (1-1 sitter, paper gowns) and consult psychiatry. A classmate on the psychiatry service shows up. We interview the patient together. He reports that he has no active suicidal ideation since he drove into the oncoming car. The job of an inpatient psychiatrist is to determine whether the patient needs to be admitted to the psych after being medically cleared by the primary team. Even a patient who tried to kill himself 24 hours prior does not meet criteria without active suicidal ideation. Therefore, he will be referred to follow up with a different psychiatrist in an outpatient clinic two weeks later. It is the patient’s responsibility to call and make the appointment and then show up. Everyone knows that this won’t happen, but nobody takes ownership of the patient’s mental health and, even if the patient did take the necessary initiative there would be no continuity of care.

He undergoes surgery that evening for his hip. We also get a consult for radiation oncology. Why? Fractures that involve the acetabulum have a high risk of developing impingement as remodeling creates spurs into the hip joint. To prevent this, there are two options, a two week course of strong NSAID, or radiation to the hip joint to stop remodeling. He undergoes radiation the following day.

Tuesday is the simulated patient exam, starting with with mesenteric ischemia (poor circulation to the small bowel). I walk in to a screaming 60-year-old. The challenge is to perform a physical exam while she is squirming on the bed in pain. After the encounter, I’m writing a note and able to view the PMHx (medical history). The diagnosis becomes clear after reading about the two previous heart attacks and paroxysmal atrial fibrillation. The second patient has classic cholecystitis (inflammation of the gallbladder). The patient reports nausea, vomiting and RUQ abdominal pain. When I ask her to take a deep breath while applying pressure under her right ribs, she jumps off the table (positive Murphy’s sign). She also fits the “Fat, forty, female and fertile” saying for gallbladder pathology. 

The SHELF exam consisted of 110 questions over 2.5 hours. Questions were mostly second order. They would present a patient, and you would have to determine the initial management step for this diagnosis. Examples:

1. A patient with sudden onset of abdominal pain and vomiting presents to the ED. Pain localized midway between umbilicus and RLQ. Should the patient under surgery, CT scan or ultrasound? (Older docs would be content with a clinical diagnosis of appendicitis, but the board wants CT confirmation.)
2. What is the work up of an elderly patient with painless jaundice? CT scan or an endoscopic retrograde cholangio-pancreatography (ERCP, a procedure where a scope is placed down the esophagus into the stomach and duodenum; contrast dye is injected into the biliary tree under live x-ray to evaluate for any stricture or gallstone obstruction)?
3. Should you give antibiotics or undergo surgery for uncomplicated diverticulitis?
4. Patient with air-fluid levels on abdominal x-ray. Surgery or aggressive bowel prep?
5. What is the most likely loss of function for a midshaft humeral fracture? Axillary or Median nerve palsy?

I got 79 percent right. The mean across all medical schools is 74 (standard deviation: 8), but these are averaged without regard to rotation order. Surgery, Pediatrics, and Internal Medicine are known as the most challenging SHELF exams. Studying more wouldn’t have helped much. Recommendation: study the indications for exploratory laparotomy, management of appendicitis, and cholecystitis.

My Step 1 score is back. As the exam questions are changed, it takes a few months before any scores can be calculated. I get 237, disappointing because my last two practice scores were 245 and 252. (Passing is 194, mean across all medical schools is 229 with a standard deviation of 20.) Starting with the questions and practice exams earlier in the year would have helped. The best strategy seems to have been starting the UWorld questions in August and resetting the program to go through them again during the study period. Jane didn’t do that, but she made it through all of the UWorld questions and snagged a dermatology-worthy 249. Our Dean of Student Affairs is ecstatic with the class average score of 239.

[Editor: The 237 should be fine for dermatology if our author/hero checks the “Related to Elizabeth Warren in the Remnant DNA Tribe” box!]

Statistics for the week… Study: hours. Sleep: 6 hours/night; Fun: 1 night. Burger and beers with Mischievous Mary, Lanky Luke and Geezer George.

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

After a Sunday reprieve, Monday begins two back-to-back trauma alerts that force us to cut rounds short.

A 16-year-old 220 lb. 6’6″ African American high school football star flipped an ATV during a morning ride. As he is transported onto the trauma bed, he repeatedly screams, “I can’t move my legs!”. He has no movement or sensation in either of his legs. A CT shows numerous vertebral fractures. Most likely complete transection of thoracic spinal cord. Neurosurgery is consulted. Nothing to do now but wait. The attending: “We won’t know final outcome until about 48 hours when spinal shock resolves.”

He spends two weeks in the hospital working with physical and occupational therapy. He is paralyzed in both legs. He becomes agitated and aggressive with the therapists, calming down only when his mother and brother are present (there is never a visit from the father and we are trained not to ask). His football team visits after one week in the hospital. After one week, he is ready for rehabilitation, but the social worker struggles to find a good child rehab facility that will accept our state’s Medicaid insurance. My attending: “He would be a fantastic candidate for a few out-of-state adolescent rehab facilities, but I doubt this state’s Medicaid will cover them.” I am reminded by the young paraplegic who was admitted last week for a Stage IV decubitus ulcer (to soft tissue or bone) and sepsis rule out. If he does not take care of himself, this will also be his eventual fate. 

The next trauma alert arrives while the 16-year-old is in the CT scanner. An 18-year-old presents with a gunshot wound to the right leg. He appears stable, with intact pulses and sensation in the lower extremity. EMS reports that he was running away from a gang shootout (our patient is African American; perhaps he got on the wrong side of our active Hispanic gang, MS-13). Somehow the bullet missed all vital structures, just piercing muscle and fat. The attending comments: “The cardinal rule of trauma is that only the good die. If you are a productive member of society, paying taxes, a respectable member in the community, father of three, then that bullet will have bounced off the femur into the abdomen ripping up the pancreas, and piercing the lung. If the patient is a gangbanger, then it’ll just miss everything. The good die young.” I throw a suture in the entry wound, and we admit the patient to the floor. (I heard a news story about the gang battle during the drive home.)

We continue rounds where I meet an overnight MVC admission from yesterday. He is a suboxone clinic patient (monthly group therapy for opioid abusers ending in the dispensing of opioids) and is anxious to avoid being stereotyped as an addict. His trauma from the car accident was not severe, but the ED gave him tons of pain meds to overcome his years of tolerance for opioids.

He has not had a bowel movement in three days so we explain we need to transition him from scheduled Q6H (every six hours) to “as needed” narcotics. We propose scheduled acetaminophen and NSAIDs (e.g., Advil) with breakthrough Toradol for pain control. “Oh I don’t want that stuff. NSAIDs are bad for you.”

The rest of the week is uneventful except for another ATV accident, this time in a 14-year-old. She has a Colles fracture (fracture of distal radius from falling onto outstretched hand), and a few abrasions. We also have two elderly ground falls requiring hip surgery: trochanteric fracture requiring pin, and femoral neck fracture requiring hip replacement. 

I had expected two weeks of running all around the hospital in response to urgent pages and watching dramatic life-saving surgeries. Instead, despite the best efforts of our local gangs, drug abusers, seat belt scoffers, ATV enthusiasts, and motorcycle riders, it was mostly waiting around. We had more “trauma” during the week of nights (Year 3, Week 3). Much of “trauma” turned out to be social work, e.g., predicting who would be a motivated candidate for inpatient rehab and persuading insurance companies that OT/PT will be effective. Patients may occupy a bed for a week receiving no significant care while the social worker enrolls the patient in Medicaid and then negotiates with Medicaid regarding the new beneficiary.

Summary of two weeks of trauma: I learned the ABCs (Airway, Breathing, Circulation) for initial trauma evaluation and some fracture management. Work started just after 6:00 am and I was usually gone by 4:30 pm. The emergency surgery service option probably would have been more educational due to its higher caseload.

Saturday: Jane’s sister is at the hospital until 10:00 pm, well past her 7:30 pm scheduled shift conclusion, and stops by our house on her way home. “An 18-wheeler going 65 mph hit three highway workers, father, his son, and the son’s best friend. The father dies on impact, the 30-year-old son is medevaced to our hospital, and the best friend is medevaced to an outside facility because our ICU is full. Now, keep in mind about 30 minutes before he shows up, we get a self-inflicted GSW [gunshot wound] to the chest resulting in a massive pulmonary contusion and injury to the IMA [inferior mesenteric artery, supplying the colon]. He had shot his girlfriend who had died in the trauma bay. So we have one patient who is bleeding out into his chest and abdomen, and [Dr. Cruella] comes running in and performs a bedside thoracotomy [opening of the sternum and ribs] and x-lap [exploratory laparotomy] on the GSW. Meanwhile, we are coding the 30-year-old as he goes in and out for 30 minutes of VFib [ventricular fibrillation, serious cardiac arrhythmia]. His wife is crying holding their one-year-old daughter. Dr. Cruella is running between the GSW and the highway worker. We finally get both patients stabilized. He is brain-dead, but everyone except Dr. Cruella is in denial. We perform two nuclear perfusion scans before the wife accepts.

“Time of death is called. My CNA [certified nurse assistant] and I then have to deal with post-mortem poops before the family comes in. And let me tell you, post-mortem poops are the worst. Everything comes out. Worse than C diff [clostridium difficile infection of colon]. I tell my CNA to watch out as we turn him. As we’re dealing with this, three gigantic birds, maybe vultures or something, fly right up to the window. It was the freakiest out-of-this-world experience ever, like a sign from God. [coworker nurse]’s jaw dropped. Was that the three souls leaving this world?

“After we cleaned the room and changed the sheets, my coworker and I offer to get a handprint for the daughter. The wife thanks us. We then realize he has a huge cast on his hand. We try prying it off, then ask if a footprint would suffice. We then don’t have enough ink in the ICU so we’re struggling to just get a toe print. We eventually find some from upstairs. The family comes in to say their farewell before we remove him from life support. They stay in the room for more than an hour.”

Statistics for the week… Study: 12 hours. Sleep: 6 hours/night; Fun: 0 nights. Jane and I grab a beer Friday evening, and then study the weekend away before exams.