(For reference, "Medicine" refers to internal medicine as a specialty; "medicine" to the field in general. Hopefully that will prevent some confusion.)
I often get questions about what kind of doctor I'm going to be. At this point in my life, I can't say for sure (even though Diana would like the answer RIGHT NOW). I can say that Internal Medicine suits me well. Why? Because it allows you, nay, even encourages you, to be skeptical.
For the past week, I've had a very interesting patient (see my previous post on being "interesting"). He was good-interesting in that his diagnosis was a mystery while at the same time he was not in danger of "crumping", to use ward lingo. In short, he was a man in his 60's who was brought into the ER by his son for what amounted to failure to thrive. He acted confused, hoarded possessions and rotten food in his house, and was isolating himself. His only complaint was abdominal pain, but he was extremely unkempt and in generally bad shape. What was interesting about him were his labs, which suggested that he had a hidden infection, that his red blood cells were slowly bursting like balloons, and that his liver was failing to produce many essential proteins. As we always do, we came up with what's called a "differential diagnosis", which is a list of all the possible explanations for what's happening. Ideally, there is one unifying theory, but in reality there are often many processes occurring at the same time.
Most of the other people on my team thought that he had a Vitamin B12 deficiency. I presented the case to my classmates with the attending physician in charge of medical education. We went through the differential diagnosis, discussed the labs, and even looked a smear of the patient's blood under the microscope. All signs pointed to B12 deficiency. The attending confidently stated that this case was "classic" for B12 deficiency. On the board where we keep track of our patients, next to the patient's name "abdominal pain" was replaced with "B12 deficiency". Fortunately, there is a simple test to determine if the patient is indeed B12 deficient. Unfortunately, it takes days for the result to come back.
I didn't buy it. When this patient was admitted, I stayed up all night on call trying to explain what his labs had shown. B12 deficiency was one of the first things I considered, and I thought it was very likely. But I just wasn't convinced that it could explain everything. I tried not to be too vocal in my dissent because one of the most important lessons you learn in 3rd year is that after two years studying your butt off, you still don't really know much. But every once in a while I couldn't resist registrating my dissent. After we had looked at the patient's apparently convincing blood smear (the matter of the blood smear deserves a separate post) and my attending made his remark about this being a "classic" case, I said, "So what are we going to do when his B12 level comes back normal?" I felt like I could say this because my impression had been that skepticism is rewarded in Internal Medicine - you just better have a good reason to be skeptical.
The B12 level came back that afternoon and was normal. It was not even in the borderline range, which is a problem with B12 tests. Based on this result, it was virtually impossible that the patient was B12 deficient. It was late in the day though, and no one on my team was around to watch a wave of vindication light up my face. Naturally, I went to see the attending, and when I told him, he just laughed and laughed. He loved that he was wrong! And this is the attitude I've seen while on Internal Medicine.
Most of the Medicine doctors I've met love a diagnostic challenge, and they know that nothing in medicine is certain. That's why it's okay to be a contrarian. When it turns out that being contrary is correct, the pressure is on to provide an alternative explanation: you sit and review all the data, you talk with various people, you devise crazy explanations that you know sound ridiculous. I find that this process suits me very well. Those of you who know me well know I can be something of a skeptic - I've even been accused of being a contrarian. In my own defense, being skeptical means not accepting assumptions without reason. It requires examining your thinking at each step. Medicine seems to attract these kinds of minds and tends to be one of the more intellectual fields within medicine. Medicine doctors are not just intellectuals though, they also have more contact with patients than most other physicians in the hospital (not to mention that most Medicine docs work outside the hospital). For that reason, as I explained to Diana, I feel like I've found my people.
Saturday, October 27, 2007
Wednesday, October 10, 2007
To treat the patient, communicate first . . .
One of the great things about medicine is that you meet so many different kinds of people, and your job requires that you learn something about them.
When I was on call recently, I went down to the ER with the intern on my team to see a man who needed to be admitted for new onset diabetes. Diabetes is one of the most common diseases to see in medicine, certainly top 5 at least. What is less common is to meet a grown man who is deaf (from birth), mute, illiterate, and who does not know American Sign Language (ASL). Think about that for a minute. This man neither hears words nor sees their written representations. Can he have any conception of language? When I met him he was with a "patient advocate", a social worker who also happens to be deaf. They were able to communicate somewhat, primarily through gestures and picture cards, but since he was mute, his interpretation of what the patient said was communicated to me through writing. I found this situation sort of intriguing, but it's also frustrating because he was a sick man with the onset of a new chronic disease which requires complex management for the rest of his life. How do you explain to someone who communicates through gestures and pictures that the cells in his body have become insensitive to insulin, which is required for those cells to utilize glucose, which are needed to make energy? What are cells? What is glucose? What the hell is energy?
People sometimes ask me, half-joking, if my life is anything like what they see in Grey's Anatomy. Rest assured, it is not. I have not seen anyone making out in the on-call room, my scrubs are not tailored just for me, and not every patient I see requires surgery. But I have seen some cases that are strange or interesting enough to be on tv, and I have met some people who I just as easily could have seen on tv.
One final important note:
Red Sox 1, Indians 0
Yankees playing golf
When I was on call recently, I went down to the ER with the intern on my team to see a man who needed to be admitted for new onset diabetes. Diabetes is one of the most common diseases to see in medicine, certainly top 5 at least. What is less common is to meet a grown man who is deaf (from birth), mute, illiterate, and who does not know American Sign Language (ASL). Think about that for a minute. This man neither hears words nor sees their written representations. Can he have any conception of language? When I met him he was with a "patient advocate", a social worker who also happens to be deaf. They were able to communicate somewhat, primarily through gestures and picture cards, but since he was mute, his interpretation of what the patient said was communicated to me through writing. I found this situation sort of intriguing, but it's also frustrating because he was a sick man with the onset of a new chronic disease which requires complex management for the rest of his life. How do you explain to someone who communicates through gestures and pictures that the cells in his body have become insensitive to insulin, which is required for those cells to utilize glucose, which are needed to make energy? What are cells? What is glucose? What the hell is energy?
People sometimes ask me, half-joking, if my life is anything like what they see in Grey's Anatomy. Rest assured, it is not. I have not seen anyone making out in the on-call room, my scrubs are not tailored just for me, and not every patient I see requires surgery. But I have seen some cases that are strange or interesting enough to be on tv, and I have met some people who I just as easily could have seen on tv.
One final important note:
Red Sox 1, Indians 0
Yankees playing golf
Sunday, October 7, 2007
On Call
Tomorrow I'm on call, and I thought I would clarify what that means.
I always thought that when you were on call, you brought your pager home and went into the hospital if you were paged. I was very wrong. What being "on call" means is that between 12:30 p.m. and 4:30 a.m. my team admits any patients who have to come into the hospital (only on the Medicine service, though, surgical pts are admitted to the Surgery team on call). 95% of the patients we admit come through the Emergency Room.
So this is how it happens: my senior resident gets a call from the ER that someone needs to be admitted. That person might have a serious pneumonia, or bowel obstruction, or they are vomiting blood, or cellulitis, or any number of other medical problems. (Very sick and unstable patients are admitted to the ICU). Anyway, the senior resident calls the intern on our team, who grabs me, and we go down to the ER and interview the patient. After that, we write some admission orders, which includes practical information like where the patient will go, how often their vital signs should be taken, what meds they will take, what they can eat, etc. I then have to write a complete history, a write-up of their physical exam, and then a discussion of the patient's diagnoses and what I intend to do so make them feel better. Right now when I'm on call, I admit two patients and "follow" them until they are discharged. The morning after they are admitted, I present their story at the patient's bedside to the rest of my medical team, and we discuss the plan. Every morning after that I give my team an update and we make any changes until the patient goes home.
The last time I was on call, I admitted my two patients and was done with my work around 3:30. At that point, I went to the on-call room where there are some beds, and slept for a few hours before rounds at 7.
In spite of the lack of sleep, being on call is usually fun. It's exciting, it's busy, it's unpredictable. In some ways, it's a lot like fishing. Early in the night it's pretty low key, you're waiting for something to happen, and then a call comes from the ER. Our team admits around 10 patients per night, and I'm only really involved for two, so when someone else admits a patient, it's just like when someone your fishing with catches a big one right next to you. There's more certainty on call than when you go fishing, because it's almost a certainty that I'll admit a patient. Then when you get a call, there' s a little time to wonder what's on the end of the line. Even after you've learned a little about the patient from the ER team, you really don't know what to expect until you meet them.
This brings me to one of those dirty little secrets in medicine: the more sick the patient is, the rarer their condition, the more exciting that patient is. I try to be very careful with my language, but if you ever hear a doctor or medical student say they have a "very interesting patient", that patient is either very sick, has a very rare disease, is unique for some other reason (like they were injured in a very unusual way, for example), or some combination. The last time I was on call one of my patients had a very rare skin and muscle disorder along with diverticulitis (a potentially serious infection of the colon). There's definitely part of your brain that is trained by medical school to think, "sweet, this guy has dermatomyositis! Are those Gottron's papules?!" Dermatomyositis is not usually a life-threatening illness, but thinking something like "wow, that woman has necrotizing fasciitis!" is a bit more troubling because it is often fatal. You see the problem.
In medical school we learn about disease so that we can help real people, but there is something about that learning that depersonalizes patients. Every medical student wants to see a case of necrotizing fasciitis, but no medical student wants any person to have necrotizing fasciitis. I resolve this dilemna by reminding myself that disease is inevitable, and that if it is to exist, I should know about it. The key is to remind yourself that it is the patient who has the disease, not the other way around. That doctors have to remind themselves of this seems ridiculous to people outside the medical profession but it frequently happens.
As I mentioned, I'm on call tomorrow, so I need my sleep tonight. I'll post again soon.
I always thought that when you were on call, you brought your pager home and went into the hospital if you were paged. I was very wrong. What being "on call" means is that between 12:30 p.m. and 4:30 a.m. my team admits any patients who have to come into the hospital (only on the Medicine service, though, surgical pts are admitted to the Surgery team on call). 95% of the patients we admit come through the Emergency Room.
So this is how it happens: my senior resident gets a call from the ER that someone needs to be admitted. That person might have a serious pneumonia, or bowel obstruction, or they are vomiting blood, or cellulitis, or any number of other medical problems. (Very sick and unstable patients are admitted to the ICU). Anyway, the senior resident calls the intern on our team, who grabs me, and we go down to the ER and interview the patient. After that, we write some admission orders, which includes practical information like where the patient will go, how often their vital signs should be taken, what meds they will take, what they can eat, etc. I then have to write a complete history, a write-up of their physical exam, and then a discussion of the patient's diagnoses and what I intend to do so make them feel better. Right now when I'm on call, I admit two patients and "follow" them until they are discharged. The morning after they are admitted, I present their story at the patient's bedside to the rest of my medical team, and we discuss the plan. Every morning after that I give my team an update and we make any changes until the patient goes home.
The last time I was on call, I admitted my two patients and was done with my work around 3:30. At that point, I went to the on-call room where there are some beds, and slept for a few hours before rounds at 7.
In spite of the lack of sleep, being on call is usually fun. It's exciting, it's busy, it's unpredictable. In some ways, it's a lot like fishing. Early in the night it's pretty low key, you're waiting for something to happen, and then a call comes from the ER. Our team admits around 10 patients per night, and I'm only really involved for two, so when someone else admits a patient, it's just like when someone your fishing with catches a big one right next to you. There's more certainty on call than when you go fishing, because it's almost a certainty that I'll admit a patient. Then when you get a call, there' s a little time to wonder what's on the end of the line. Even after you've learned a little about the patient from the ER team, you really don't know what to expect until you meet them.
This brings me to one of those dirty little secrets in medicine: the more sick the patient is, the rarer their condition, the more exciting that patient is. I try to be very careful with my language, but if you ever hear a doctor or medical student say they have a "very interesting patient", that patient is either very sick, has a very rare disease, is unique for some other reason (like they were injured in a very unusual way, for example), or some combination. The last time I was on call one of my patients had a very rare skin and muscle disorder along with diverticulitis (a potentially serious infection of the colon). There's definitely part of your brain that is trained by medical school to think, "sweet, this guy has dermatomyositis! Are those Gottron's papules?!" Dermatomyositis is not usually a life-threatening illness, but thinking something like "wow, that woman has necrotizing fasciitis!" is a bit more troubling because it is often fatal. You see the problem.
In medical school we learn about disease so that we can help real people, but there is something about that learning that depersonalizes patients. Every medical student wants to see a case of necrotizing fasciitis, but no medical student wants any person to have necrotizing fasciitis. I resolve this dilemna by reminding myself that disease is inevitable, and that if it is to exist, I should know about it. The key is to remind yourself that it is the patient who has the disease, not the other way around. That doctors have to remind themselves of this seems ridiculous to people outside the medical profession but it frequently happens.
As I mentioned, I'm on call tomorrow, so I need my sleep tonight. I'll post again soon.
Monday, October 1, 2007
Medicine introduction
I don't have much time right now, but I've just finished my Psychiatry rotation and now I'm on Internal Medicine. Again, I'm at Harborview, the large public hospital here in Seattle.
I know a lot of people are confused about what Internal Medicine is, but for now I'll just say that these are the doctors who take care of you if you have to be admitted to the hospital for common problems likes pneumonia, or pyelonephritis (kidney infection), heart attack, stroke, etc. Of if you're at Harborview your patient may have many of these problems concurrently. In just one day, I've been amazed how complicated some of the patients are. Medicine doctors often consult other specialties (infectious disease, neurology, orthopedics, surgery, etc), but ultimately it is usually the medicine doc who has to put it all together, incorporating the recommendations of consultants to form a master plan.
More soon but I need some sleep.
I know a lot of people are confused about what Internal Medicine is, but for now I'll just say that these are the doctors who take care of you if you have to be admitted to the hospital for common problems likes pneumonia, or pyelonephritis (kidney infection), heart attack, stroke, etc. Of if you're at Harborview your patient may have many of these problems concurrently. In just one day, I've been amazed how complicated some of the patients are. Medicine doctors often consult other specialties (infectious disease, neurology, orthopedics, surgery, etc), but ultimately it is usually the medicine doc who has to put it all together, incorporating the recommendations of consultants to form a master plan.
More soon but I need some sleep.
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