Doctor

Come Back One Day and say ‘Hello’

2007-03-05T21:30:00.000-08:00

Tonight, Bob Woodruff appeared on The Daily Show. Funny I should start my first post back with this one particular fact. But it is one that stands out tonight. I will get back to it soon.

I promised to tell you about the life of a Hospitalist in a community hospital and that I shall do.

Medicine in a community hospital is a little different than in Academia. During residency, the patient belonged to an internist if he/she was on the medicine floor. But if things turned for the worse and that same patient was transferred to the ICU he would then be under the care of a new attending, the ICU attending serving in the unit.

But things in a community hospital are a little different. Here, I am your attending in the ICU as well as when you improve. I will be your doctor on the medicine floor too. And sometimes, if you go to the rehab floor here, I’ll still see you from time to time, just to make sure the old ticker is still ticking. Of course I consult with an intensivist if my patient is in the ICU, however, the final call on what goes in and what stays out remains mine, my responsibility, my decision.

In my short nine months as a Hospitalist I’ve accompanied many patients through their journey in this community hospital. I recall many whom I can honestly say would not be alive today if it wasn’t for something I did or didn’t do for them, whether they know it or not.

Some of you may misunderstand and figure I managed to pick up a god complex during those months too but that’s not what I’m driving at.

I guess the biggest drawback to the Hospitalist life is what dawned on me tonight. Looking at Bob Woodruff, I was looking at a man dressed in a suit, handsome, intelligent, well spoken, interesting, a man with a family who loves him and who seems to care much for his family. The entire time, I really mean this, the ENTIRE time I watched him I imagined the way he must have looked in that ICU in Bethesda. I saw him intubated, on a respirator, bandages across his head, half his scull removed. I saw lines, feeding tubes and urinary catheters. I saw nurses hanging IVs and getting CVPs. I saw the tears in his family’s eyes as physician after physician told them that their father was ‘critical’. Lucky if he makes it.

The single BIGGEST drawback to the Hospitalist life is this moment. When your patient has walked through the shadows of hell and has come out alive. And not just alive, Intelligent, Handsome, well spoken and a real family man, even dresses well.

This moment would have never happened if not for those same doctors and nurses in Bethesda. But if not for television, they would never have gotten to see what it was all for. Because patients almost never return as their true, every day selves. Only in another hospital gown.

I am still waiting for just one of my patients to come back to say hello. I hope one day one will.

Hope he comes dressed in a suit.

Hospitalist

2007-03-03T16:14:00.000-08:00

I don't even know if I still have a readership...IS ANYONE OUT THERE????

It's been a long while. Oh boy, how much has happened and where should I even begin.

I am a hospitalist now. It's been close to nine months that I am doing this job and it feels like internship all over again. Learn fast, on the fly, hold on it's a bumpy ride.

Private practice is sooo different than Academic. Things run much more smoothly here and they don't. Patients get much better care here....and they don't. I'll explain, I'm sure, soon. It just feels good to actually be back. I will not post much and certainly not on weeks I am working. But I'll have some fun with it.

For those of you who actually remember future intern. She is two years old and the most adorable thing I've ever seen.

We are expecting a son, any day now. But what should I call him?

Intern's Lie

2006-06-29T07:10:00.000-07:00

I’m drawing a blank. In these instances, I have learned, the optimal solution is to post something you’ve written in the past. I wrote this in the beginning of my second year of residency. Looking back I realize it’s kind of immature, but, right on the money!

Tomorrow, 7 am sharp, I embark on a new journey. I will be head of the team. This team will encompase one Attending, one Resident (that is I), two Interns (first year residents), one Sub-Intern/ fourth year med-student (from here on the “Sub-I”), and two third year med-students (a.k.a. “Students”).

To serve the readership yet unfamiliar with the medical hierarchy that governs today’s fine medical establishments I will now take the time to explain this stepladder of ass-slurpers. The understanding of this is essential for our future relationship and so if you have any questions feel free to ask.

I will comprise the list to range from least kissed ass to practically dripping. Remember, each member of the team has a primary goal, a secondary goal (if applicable), friends and enemies. It is long; I am sorry for this, but essential for the upcoming month. Let us begin:

1- The Students/ Third Year Med-School

Primary goal: To impress Attending and Resident with knowledge we were sure they never had. Secondary goals: To cloud a simple clinical scenario by suggesting that the patient has as many extremely rare diseases as possible, to name a disease the Resident hasn’t heard of and to send out for as many of the most expensive blood tests we have as the Resident allows. The sub-I is their best friend as he is closer to the resident and is always up to date on their performance thus far. Enemy: Interestingly enough, they are each other’s enemy as they are always being judged comparatively to each other. This undercurrent of hate is masked very well and only a thorough Freudian understanding of the subconscious can uncover it.

2- The Sub-I

Primary goal: Impress attending, Sub-I’s need recommendation letters for the residency match so they too can be taken advantage of by residency programs and government. Secondary goal: Discharge patients, less patients mean less work and try not to sound like Student by naming any rare disease.

The Sub-I’s friends are the Intern and the Resident, possibly third year but only if they agree to do his blood draws. Enemy: Patients with extremely rare diseases (makes Sub-I extremely uncomfortable as he now has to sound like Student).

3- Intern

Primary goal: Discharge patients. Intern will do or say anything to achieve this goal as he/she is usually overworked and would love to have one less family and upcoming tragedy to deal with. Secondary goal: Anything that ends in less patients (I cannot stress this enough).

Their friends are the other interns, amazing bonus point if able to really swing Resident to their “point of view” (often wrong!). Enemies: Patients!!!!
4- Resident (my new position)

Primary goal: To impress Attending and Chief of Medicine while also keeping Intern happy, motivated and feeling that Resident is truly on his side. Secondary goal: Constantly remember that Interns LIE! Again, they do anything to get patients out and Resident must continually double check Intern behind Intern’s back as INTERNS LIE! Friends: The Attending and other Residents. Enemies: Everyone on a certain level: as Interns LIE, Sub-I wants information primarily for Student, Student wants to name rare disease and make Resident look bad. To counteract Student, Resident must immediately say “I don’t know that but why don’t you give us a presentation on this tomorrow morning” (Gotcha Ya Bastard!).

5- Attending Doctor

Primary goal: Come for 2 hours in morning, teach, and leave as fast as possible, keep name out of chart so no one knows who to sue later. No Secondary goal. Friend: All. Enemy: No one. Remain completely oblivious to the ass smooching going on a round you. Wipe ass off after morning round.

6- Chief of Medicine

Primary Goal: Teach and run Medicine Department. Secondary goal: Absorb all ass-kissing, taking it all in as one continuous lick that lasts for many years. Secondary goal: Try to remain seemingly very humble, once in while give a lecture which makes every resident in the room feel like he knows absolutely nothing/ give up his medical license and go back to medical school.

This is the system within which we all operate. If there are any questions please feel free to ask. Tomorrow, I will do my best to avoid all questions and appease Intern to join my view of things. This will be my greatest chess match yet.

How We Die in America

2006-06-23T09:47:00.001-07:00

In undergrad we had a course titled "life and dying". I'll never forget the first words my instructer said as he entered the room: "I don't know why they call it life and dying when the course is really all about dying".

What a great course too. It was there that I visited my first hospice, learned about the choices that people in our culture commonly make when it comes to their own (impending) death and the realities that those who never think about this have to face.

Residency was a course in itself. I don't think a day went by where I didn't have to do something to a patient that I knew I would never want done to me had I been in their situation. The truth is that unless a patient specifically states his/her wishes in advance we are left with little choice but to do everything in our power. Sometimes, that translates into procedures, painful ones, dangerous ones as well.

The Schiavo case brought the issue to the public's attention and really was a prime example of how the beliefs of family members and the lack of public knowledge of one's wishes can cause tremendous chaous.

A reader requested that I post a link to this article. The article has some interesting revelations about the contrast between how we "think" we're going to die and how we're actually likely to checkout. It's from the new book, "UNPLUGGED: Reclaiming our Right to Die in America."

Here's a little exerpt:

Our doctors are equally subject to technology's allure. They learn in medical school to assess, treat, and cure. They then move into a hospital culture where a death, even among the aged, is seen as a failing. The young Dr. Lown in 1959 plied the silver paddles on the chest of a living human for the first time, and saw a miracle; a racing, out- of-control heart instantly returned to a normal heartbeat. The young Dr. Potter in 1963 compressed a chest and saved a hardware store owner, and the whole town knew it. Their tools were unbelievably primitive compared to the arsenal available to a young doctor today, but the miracles are equally wonderful. How could we deny today's doctor such joy? Or today's patient? Why in the world would we want to?

In truth, we don't want to, and we shouldn't want to. We want the technology, and we want the cure. When surveyed, the majority of us say that when our dying comes, we hope to be at home, free from pain, surrounded by loved ones, and not hooked up to machines. In the abstract, that's likely true. We also very much want to be hooked up to those machines right up to the very moment when the doctor is sure that those miraculous tools can't fix us. Trying to find that exact line is no easy business.

Moving!

2006-06-11T04:26:00.000-07:00

This time I mean for real. I am in the middle of a move to upstate NY. If not for this GPS thingy that I bought I'd still be lost on some back country road, withering away.

Congrats to Dr. Charles on making the move to his new address. We started blogging together and, at the beginning, had very similar blogs. He would blog literary stories of his start as a family physician and I would blog about my experience as a resident. We found each other pretty quickly back then and have found a way to keep in touch, maybe one day we'll even meet face to face.

But the times they are changing. I am nearly finished with my residency and he is nearly finished being a "starting" physician. Now, it will be my turn to blog as a beginning hospitalist and he can dish me the wisdom of one who is more advanced.

I am planning on writing a post that's a summary of my residency when I can see through the pile of boxes in this office. I was even thinking about writing a book about my residency and incorporating a lot of the madhouse posts into it somehow. All ideas that will have to wait for me to pass the boards.

Hopefully, I will have the time to write soon. Judging by my first week in my new local, time will be one of the things I will have plenty of.

Birthday

2006-05-27T05:07:00.000-07:00

Just wish me a happy birthday and move on because soon I'll be so soaked up in alcohol I may just answer inappropriately!

Thirty two and counting for the soon to be full-fledged doctor

Electronic Medical Record (Oh Doctor...)

2006-05-25T09:25:00.000-07:00

This week's issue of JAMA has a commentary essay about the new Electronic Medical Record system. I'd have to say that it's right on the money for how inconvinient sifting through any chart is these days. The essay is available here for free and is written in a format that really drives the point home! (highly recommended)

EMR (Electronic Medical Records) is the new standard in medical technology. Basically, hospitals are hoping to have the entire medical record of patients available on the computer system, including all notes written for that patient. You can see the potential benefits, however, the idea has run into a few obstacles:

While EMR is highly efficient in producing notes, virtually all of its notes are longer, recombinant versions of previous notes. Even notes of different authors are morphed by EMR into clones of one another. As physicians have become more adept with the time-saving features of EMR, their notes have been rendered incapable of conveying usable information by their bloated and obfuscated nature.

For one, the notes never change. The longest note I've seen thus far here was seven pages long. SEVEN pages for a daily progress note. By a Doctor!

Moreover, EMR encourages everyone to copy-and-paste the notes of everyone else so that notes become the same from author to author as well as from day to day. Even consultants are assimilated into the oneness of the EMR Borg. A cardiology consultant recently copied-and-pasted the intern's note into his own, even including "consult cardiology in AM" in his recommendations. Perhaps he meant consult a more thoughtful cardiologist.

I'm all for making the intern's job a little easier (actually, no I'm not!) but this is really starting to get ridiculous, not to mention, downright dangerous.

For example, I am aware of a case where a patient expired due to what the team thought was a Deep Vein Thrombosis that traveled to the lungs. The team was aware of the DVT and were treating it appropriately, however, the intern's notes make no mention of the possible DVT. They were continually copied and pasted. The doctors who are now being sued have very little evidence to back them with no documentation.

It should be pointed out that EMR has some laudable aspects. Notes can be created quickly with minimal cognitive effort, and their impressive length implies diligence and attention to detail.

"Minimal cognitive Effort" is the correct term here.

Grand Rounds

2006-05-16T09:50:00.000-07:00

This week's Grand Rounds are held at Doc Around the Clock.

and someone's trying to put together a Pediatrics Grand Rounds.

David Blaine is Dying to Breath

2006-05-13T18:58:00.000-07:00

About four years ago I ran into David Blaine in a crowded New York City subway station. He was performing his usual card tricks for the local street gangs. I had admired his magic for years and really thought that, as the locals say, he “Got Skillz”. I watched for twenty minutes and then went on my way but it was the highlight of my day. There is no doubt his talent is far superior to others in his field.

Of course, if you were one of the lucky few million that caught his special the other night on ABC then you probably already know what I mean. As of late though, he’s taken to doing all sorts of ‘pseudo’ tricks, like living in a bubble full of water for one week in the middle of Lincoln Center.

“Why the hell would anyone want to live under water for one full week?” I’ll venture to say it’s good for publicity. But why am I even discussing the subject on a medical blog?

Here we are and it’s Sunday night and there is a man on television about to suffer through a live apnea test in front of the whole world! And in my twisted doctor mind part of me wished I could test his blood gases, I could peak at his pH. Maybe even figure out how he would do it. So I kinda did and I thought I would share some of what I’ve learned with you. But before I launch into that, you must be wondering what the apnea test is.

Taken literally the word “apnea” means “cessation of breathing” and the main purpose of this test is to determine if a patient is clinically brain dead. It’s used mainly when it is believed that the patient underwent such a catastrophic event that he/she no longer has any brain function, including the drive to breath. We believe that brain death is the equivalent of death and we use the apnea test, as one test among others, to confirm clinical brain death.

How is the test performed? The patient is disconnected from the ventilator for ten minutes and monitored for spontaneous breathing. At the same time, we continually monitor their blood gases (the concentration of oxygen and carbon dioxide in their blood) throughout the test. When a human being ceases to breathe the concentration of carbon dioxide in the blood rises and the concentration of oxygen falls. Patients fail the test if the concentration of carbon dioxide in the blood rise to twenty above baseline levels and no spontaneous breath is recorded. But how does all this relate to breath-holding in a live human being. Well, it technically doesn’t, but the same process will go on there as well. Slowly, the amount of oxygen in Blaine’s body will dwindle as the carbon dioxide level will rise. Slowly but surely, the feeling will become unbearable and his brain will begin to signal frantically for oxygen. But at what point will all this become so unbearable that it will override his will not to inhale?

There aren’t many studies that have investigated the human ability to breath-hold. But those that have been conducted have shown that breath-hold duration depends on numerous variables. One fact of solace was that, regardless of the circumstances, human beings seem incapable of holding their breath to unconsciousness.

For one, breath hold duration is increased by increasing lung inflation. One would expect that lung volume would stay constant during breath holding but this doesn't appear to be the case, mainly due to complicated pressure gradients that are beyond the scope of this discussion. However, one theory was that the breakpoint (point at which breath holding is no longer possible) may be dependent on some minimum chest size when this deflation would cause sufficient feedback to the brain respiratory center to initiate a breath. This however does not appear to be the case.

Interestingly, breath holding duration is almost doubled by either starting with a lower than normal blood carbon dioxide level, which can be achieved by hyperventilation or holding with gas mixtures that have an excessive concentration of oxygen. For those who witnessed the event, Blaine was coached to hyperventilate (purge) prior to going under, presumably to decrease the carbon dioxide levels in his blood. Obviously, he did his homework.

Increased metabolic rates decrease breath hold duration. Likewise, decreased metabolic rates increase it. I would suppose that it wouldn't be unreasonable to think that the tank that Blaine used was probably cooled to temperatures that would decrease metabolic demand during the final event. Surely, Blaine would have taken advantage of this phenomenon.

Do arterial chemo receptors dictate the breath breakpoint, maybe yes and maybe no. the fact that there is no consistent carbon dioxide blood level at breakpoint in study subjects suggest that this is not the case, however, one experiment in patients whose arterial chemo receptors were not functional showed that these subjects could breath-hold almost double the time of healthy subjects. I can't put it past Blaine to somehow alter the response of his chemo receptors prior to the event but I believe it is unlikely.

The bottom line:

Was I the only one who thought Evil Knievil was going to bitch slap Blaine during the interview? I bet not.

During the interview Blaine demonstrated that he could hold his breath for approximately five minutes (an amazing amount of time), or 305 seconds. if Blaine was to cool the water tank to decrease his metabolic rate and even increase his breath holding duration by 25% (no exact prolongation constant is available) than he would be able to hold his breath under these conditions for approximately 6 and one half minutes. By hyperventilating prior to starting the hold he would increase his time easily by an additional 25% which would conclude a total time of eight minutes (assuming he did not do this prior to his breath hold with kenivel).

Blaine was able to hold seven minutes and ten seconds. Pretty damn good but not much improved from his prior attempt with kenivel once all other factors are taken into account.

Overall, I think it’s safe to assume the event was more of a publicity stunt for Blaine’s magic than for actually breaking the world record. The special was good. Some of the tricks were unbelievable. Now all that’s left is to see what he’s going to do next.

Heck, he’s had a week under water to think about it!

A great article on the factors involved in breath holding can be found here.

High-Fiving Where the Sun Don' t Shine

2006-05-07T07:02:00.000-07:00

All three colonoscopies didn't hurt. In fact, the only thing I remember of them was the sweet dream a little versed and dilaudid can induce. The first could actually be my first anatomy class. Some previous girlfriends would beg to differ!

I was 17 years old and after years of digestive problems I finally earned a trip to where ‘the sun don’t shine’. They tried to knock me out but didn't quite get it right. Seeing the inside of my own body was, I thought, 'so cool'!

Recently, I saw a commercial on television featuring patients exiting the colonoscopy suite high fiving everyone outside. I'm not sure it quite captures the mood of relief after the experience but kudos for the public awareness campaign. I'd rather spread the word about a possible life saving colonoscopy than about the HPV test no one really needs, or the Viagra. Personally I think they should follow every Cialis commercial with one for genital herpes. But I digress.

Colon cancer is the second most common cancer in both men and women and is responsibly for nearly fifty thousand deaths per year. This year alone, 150,000 people will be diagnosed with this disease.

Although there is no study proving that colonoscopies prevent colon cancer there is a lot of indirect evidence to support this hypothesis. Early carcinomas have been found in adenomas and the distribution of the two in the colon is very similar. Guaiac stool cards have been found to decrease the rate of colon cancer, presumably because they lead to a colonoscopy.

I understand the recent popularity of virtual colonoscopy, however, from this perspective I can say it's "virtually" useless, for anything other than making the radiologists richer. The preparation for the procedure is exactly the same and at least during a colonoscopy the patient receives sedation. Furthermore, during a colonoscopy, if something is found it can be resected immediately. If a cancer or polyp is found on a virtual colonoscopy the patient will need a real colonoscopy to boot. Bottom line, from the perspective of a three time veteran of colonoscopy the prep is by far the worst part of it and it's not any more comfortable for a virtual colonoscopy.

And this is the most important reason for getting your colonoscopy. There are only a handful of cancers for which prevention is effective, the rest are either screened for (to identify those who already have the disease) or not even screened for (no effective test). A colonoscopy can not only screen but at times can actually be curative.

It seems a complete waste when a father or a grandmother dies from a CANCER that could have been cured in a matter of minutes years earlier.

So get past your homophobia and get a colonoscopy if you need one. It rarely hurts, I promise.

And take my word for it; a little Versed is a lot of fun!

Malpractice Reform

2006-04-13T05:36:00.001-07:00

Dr. Charles recently published a post concerning malpractice reform. The long of the short is WE NEED YOUR HELP! so use the link and take the extra few seconds to send the e-mail.

As for me, sorry for the extremely long blog break that will have to go on slightly longer. I just feel like I need a break. This "hobby" of mine became too demanding in my own mind.

I Love This Guy

2006-03-24T02:41:00.000-08:00

I love it when I see posts that remind me of the Madhouse Madman. I love them more when I see them as comments on my blog. Charity Doc left this comment on my primary Care post below. And...please take it with a sense of humor. I'll have no bickering on my blog:

Don't do it!! Spend the extra 2 years and do a fellowship.

Here are some ideas:

Cardiology - you will work like a dog and be consulted every time a patient c/o chest pain (which is roughly 30%+ of all ER visits). You'll cath every middle aged and old people that have a femoral pulse. If they don't, you put a pacemaker in. If they're also dizzy, make it a pacemaker/ICD combo. But on the other hand, you'll be stinkin' rich and paid very handsomely. As far as hospital politics go, you'll be coveted and treated like a god, while us lowly, replaceable ER docs wish we have your clout with the hospital administrators and other medical staffs. I've been at this hospital for over 5 years now and the CEO, COO and CFO of the hospital still don't know who the heck I am every time I see them at the staff meetings.

Nephrology - you'll work like an ox and get consulted for every Creatinine level above 1.5 But you'll make money out the wazoo because every dialysis patient is fully funded so your reimbursement rate is...CHACHING. You'll even volunteer to dialyze road kill if it has an AV shunt in. But somehow, and for some stinkin' reason, you'll moan and groan every time you look at your census list which takes up a whole page, front and back, single spaced. Those damn dialysis patients sure have a lot of medical problems. DM, CHF, PVD, HTN, CAD...the list is endless. You'll find yourself arguing with the cardiologist whether CHF is a disease of the heart or a disease of the kidneys.

Hem/Onc - You may find it too depressing. Consult the Happy Oncologist blog for this one.

Rheumatology - No pt. seems to get any better do they? Another depressing discipline.

Endocrine - how many endocrine consult have you done? As an ER doc, I've never had to called one. Maybe you should forget this one. The chaching bell ain't ringing here.

Pulmonary/Critical Care - I'm just not feeling the big chaching factor here either. They seem to bronch everybody and scan everyone's chest. Vent management ain't that much of a mystery. It just seems that way. They're the only ones that get all excited about sputum. Sloogy docs. Everyone gets PFT's. What would you do without the cigarette industry?

GI - Oh my God! While the rest of the world upchucks and toss their cookies whenever a GI bleeder shows up, the GI guys sniffs it all in and says..."Can you smell the money??!!!" Poopy docs and Golytely pushers. They do make a very decent salary though, scoping from above and below all day long.

Neurology - Every since the NIH touts tPA for ischemic strokes, these guys are consulted all the time now from the ER. They're all over the TV and radios being spokepersons as every hospital compete to get that Stroke Center designation. What a load of crap, heh? Stroke Center. The standard of care, the 3 hours window for thrombolytic from onset of symptoms is the flipping same at every hospital. Every hospital has a OT/PT department, too. So why should any "stroke center" be any different from any other hospital? Yet, they're all over the newspaper and radio touting so.

Don't get me wrong, we need primary care providers. But why be one, work just as hard as the other guys and get pay less? Do the extra 2-3 years fellowship. It's all worth it. If I had to do it all over again, and if someone were to point a gun at me and force me to, I'd choose cardiology and nephrology as a second choice. Just my thoughts. Good luck on your decisions.

www.fingersandtubesineveryorifice.blogspot.com

ER docs are crazy and because of that they have the best sense of humor in the entire hospital.

The Case of Slobodan Milosevic

2006-03-18T07:23:00.000-08:00

Talk about jumping on a case too late. Due to an extremely busy week of interviewing and clinic rotations I was unable to write about the case although I’ve been following closely.

Slobodan Milosevic, former Yugoslav president, who was on trial for war crimes, was found dead in his jail cell at the UN detention center in Hague. Mystery surrounding the cause of his death immediately emerged. Specifically concerning traces of a drug called Rifampin which was found in his blood on an earlier exam.

Rifampin is mainly used as one of the multitude of medications used to treat tuberculosis. It is unclear how traces of the chemical were ingested by Mr. Milosevic since he was not being treated for this condition at the time and the pharmacy at the detention center does not even carry the drug.

In addition, Milosevic, who later found out about the traces of the drug found in his system, wrote to the Russian embassy concerned the possibility that he was being poisoned. In November, Mr. Milosevic was complaining of headaches, fatigue and hearing problems, possibly as side effects of Rifampin use. Speculation about how traces of the drug were found in Milosevic still ruminate and includes poisoning and self ingestion. How Milosevic could have obtained the drug is unclear although reports say that he was in a “privileged setting” where many normal prison procedures were not always followed.

As for using Rifampin for the purpose of poisoning there are certainly better options. The side effects of Rifampin toxicity are numerous, however, they are generally not lethal. In addition, Rifampin can decrease the effects of other medications and there are speculations (I know you don’t like ‘speculations’) that Milosevic was ingesting the drug in order to prevent adequate treatment of his high blood pressure, possibly as a means of earning medical leave.

An Autopsy revealed the cause of Mr. Milosevic’s death to be, as one newspaper put it, a “mild” heart attack. As a matter of policy, I limit my use of the word “mild” to non-lethal myocardial infarctions.

In addition, as an anticlimax to this issue, traces of Rifampin were not found in his blood.

Reality Check (Ruthlessly Candid)

2006-03-14T13:33:00.000-08:00

I am looking for a job.

After three years of residency in Internal Medicine I have decided to forgo fellowship and go into Primary Care/Internist or Hospitalist work. I thought it would be interesting to share with you some of the offers as well as my thought process.

I think this can be interesting because due to my anonymity I can afford to be ruthlessly candid. The other reason is that as some have stated you would like to read about the true experience of being a resident, look no further.

In the past, I have done my share of complaining: about the job, the hours, the pay, the future etc. etc. I’ve stopped all that. Not because I don’t still have those same concerns but because I realize that some of my audience likely make a fraction of what an internist makes these days and so my complaining seems kind of “funny”. So please don't view anything I write here as complaining, just my honest thoughts.

And, since I always believe that two, or two hundred, heads are better than one I would certainly welcome any tips that my readership can provide, maybe something I haven’t thought about.

Before I do, I think I have to be candidly honest about my goals and current situation, so that all of you can give me the best advice:

Overall, this is the plan: My wife and I would like to be able to return to Israel to live there within 5-10 years. Since doctors make roughly $30-40,000 in Israel I do not think that I will be able to pay my medical school loans there, this is the reason why I returned to the U.S. after attending medical school in Haifa. I would also like to be able to purchase the apartment/house I will live in there, since that can be very expensive. The plan is to pay off the private loans before I go back and make enough investments in the U.S. so that I can have income that can pay off the rest of the loans by itself. Currently, we are hoping to finally purchase a home and stop renting. Preferably in a good community with good schools so that Jordan can be safe.

Current financial situation:
1. Private Student Loans: $80,000 at 6.25% variable interest. Current monthly payment can vary but minimum is rough $600.
2. Stafford Student Loans: $96,000 at 3.25% locked, monthly payments $400 over 30 years.
3. Savings: $40,000
4. Currently renting but hell-bent on buying something soon. I currently live in a major urban city and the housing prices here are on the level of prohibitive.

Thus Far: I have been to 5 primary care interviews and 3 Hospitalist interviews here is what I have come up with: I have multiple offers, here they are:

Primary Care Positions:
1. $120,000 a year. No bonus. Partnership, maybe, after two years. Housing reasonably priced.
2. $115,000 a year. Bonus once surpassing three times your income. Partnership after 3 years. Opening Concierge service possible. Housing extremely expensive.
3. $80,000 a year. No bonus. 10% of whatever you bring in. Housing extremely expensive.

Funniest trend: The more expensive housing is in the area the smaller the salary.

Hospitalist Positions:
1. $110,000 no bonus, known to be a hard hospital to work in with lots of hours of work. Housing in area extremely expensive.
2. $125,000 no bonus. Work hard. Housing expensive.
3. $140,000 with bonus. Two hours away from family and outside current city. Housing cheap. Good community. Work hard.

My current inclination is to take the third Hospitalist position since I will likely be able to save the most there. The wife and I think it is our best chance at achieving our goals even though we will have to leave the family behind.

I had intended to go into clinic based medicine but will likely hold off until I move to Israel. It is an unfortunate truth which I simply have to confront and that is that currently I cannot allow myself to enter primary care and achieve my short term goals. When I listen to my friends who entered other specialties and the offers they are getting I am extremely jealous and if I had to make the same decision again I would have chosen differently.

I Applaud Her Effor Although I Do Fear For Her Life

2006-03-13T07:45:00.000-08:00

Check out this NY Times artcle on Dr. Wafa Sultan. And here's the video they're talking about.

Hat tip to Enrico for the info.

My Conclusion

2006-03-13T07:06:00.000-08:00

Friday, I asked the readership of this blog to express their opinion on my posts which dealt with Ian Thorpe, an olympic australian swimmer, who is currently suffering of an unknown respiratory condition. My question specifically was to inquire if I was being "Unethical" in publicly stating my opinion of what I felt was the likely diagnsis. Your views were mixed. for example, Moof said:

1) Ian Thorpe is a public figure.
2) You didn't make an accusation, you made a speculation.
3) Physicians have as much right as anyone else to speculate about whomever they will - even (and especially) when the subject matter is in their field of knowledge.
4) The only problem that I can see isn't one of ethics, but perhaps one of indiscretion (gossip?) ... depending on how you see 1) public figures and 2) the nature of the speculation.

And Graham reiterated similar concerns with:

It's definitely rubbed me the wrong way since you first started posting about it. If you were speculating about something a little more benign, I don't think I'd mind. But you're speculating about something serious and terminal; I'd feel the same way if you were speculating about something like cancer or ALS, I think I'd feel the same way. (Not to mention all the stigma that comes with HIV.) I think as a physician you're automatically able to know more about some people from your training--perhaps something that a non-physician would call strange or different or normal variation, you would know it to be disease.

And then there was an anonymous blogger (a physician) who stated:

I think ethically you have to ask yourelf several questions:
1)In publically speculating, did you bring harm to the patient's character? ( gossip)2) If so, do the needs for society to know outweigh the respect for an individual's privacy?
3) By virtue of your M.D., do your speculations have greater weight, and therefore carry more potential for grater harm?

I thought all the comments were great and quite thoughtful and I appreciate you all taking the time to write them. I did have difficulty though seperating if the problem was the fact that I was speculating about HIV? Or was the problem that I was speculating at all?

Speculation by its very nature is gossip. I get paid to speculate. People pay me for my services to speculate on their medical condition based on what information I have. Most of the diagnosis that physicians make are based on "the most likely" etiology. Isn't that speculation?

So I think what bothered everyone was the fact that I speculated that Ian Thorpe may have HIV. Probably due to the fact that HIV is a disease which still carries great stigma.

It was likely my fault. I had intended to begin trying my hand at speculating on general medical issues in the media, a la CodeBlueBlog (although, I profess, could probably never be as good as he was adn I so enjoyed reading his entries). For example, was Sharon's stroke due to medical error, or more recently, what is the true reason for Milosevic's death. I just so happened to pick up on Ian Thorpe's condition as the first and in this particular case HIV was my leading diagnosis, stigma or not.

Perhaps the best advice came later in the commentary from Echo Mouse and I urge you to read it carefully. I believe some of you may be taking what you read here a little too seriously:

My view is that blogging is personal unless it's part of a business or organization. You don't affiliate your blog with your hospital, private practice or any other agency. So I view your blog as a personal blog, despite the fact that you are a doctor.

Now, when it comes to expertise, everyone has enlightenment on certain things by virtue of their occupation. A blog is a place to express personal viewpoints. Your personal views include your training as a doctor. So while speculation about someone's health might be considered wrong in your capacity as a doctor, you are not at work here, you are blogging here. Based on all of this, I don't see that you have broken the H.Oath or spread gossip. You mused on something of interest to you. On your personal blog. Granted, HIV status can kill a career but you have never claimed to be an expert on HIV nor are you being consulted about this person's health. You're just stating your thoughts. That's okay as far as I'm concerned.

One of the reasons I took a break from blogging was because it was seemingly too political for a while there. People need to stop and think. Your blog is not the NY Times nor do you work for Reuters or the AP. If they stop in to read, they need to remember it's the same as stopping in to have coffee or tea with you. You're entitled to your opinions. Trying to limit that by throwing your profession at you is the sort of thing society does to shut people up, which definitely goes against free speech.

So you see, when you stop in to read here it's just like stopping in to have a cup of coffee. So what will it be regular or decaf?

I won't have the coffee, it gives me a case of the runs.

Friday Intern Topic of the Day VII: Is the Doctor Displaying Ethical Behavior?

2006-03-10T00:46:00.000-08:00

I love comments. Yes, I agree, I do tend to be less “responsive” to commentators than other bloggers but I certainly read each and every comment that’s left here. So if you ever have something to say please take the time to leave a comment, I do love to read them.

There are, however, comments that go in one ear and out the other and others that make me think. Earlier in the week I posted an entry about Ian Thorpe. I speculated that based on the information available to me, that Ian Thorpe may have HIV. I gathered the information from press releases released by Ian and from whatever I could gather that was released by the general media. I even submitted the post to Grand Rounds. Where, somehow amid the thousand and one entries this week, it managed to get a certain amount of attention.

There was one comment left by a certain Dr. Steve that I’ve been thinking about for quite some time now and I would like to comment on it. And, I would like to hear your comments on it too:

As a fellow physician, I think it is marginally unethical of you to openly speculate, based on extremely thin second-hand guesswork that a prominent figure like the "Thorpedo" has HIV. I don't think you would like that if the tables were turned (especially if it turns out that the guess is wrong).

I actually thought it was a great comment. It didn’t contain any foul language or derogatory remarks and yet drives the same point home. Everyone, I would like you to take this as the perfect example of how to display dissatisfaction with a certain post without displaying lack of taste. Wonderful stuff and it made me think. Am I being somewhat unethical in speculating about Ian Thorpe’s condition openly on the internet?

Lately I’ve been contemplating the purpose of blogging. Other than the occasional sharing of something creative that I wrote is there really any other benefit to what I’m doing, and by extension, to blogging at all? (I contemplate too much, I know)

Here’s what I concluded:

If there is anything that we as bloggers can contribute in the big spectrum is that we are all experts at something. Likely, our level of expertise far outweighs that of the reporter who writes the column for the big media conglomerates whom we are all reading. These reporters don’t know what questions need to be asked because they are not lawyers, doctors, cops or accountants. They are reporters and that is the only thing they know.

Ian is not my patient. I took an oath to protect the privacy of my patients. It would be unlikely that, Ian Thorpe being who he is, other doctors have not already discussed the possibility on big media in Australia. In addition, Ian’s condition is being discussed everywhere, last I checked, 300 articles around the globe this week alone.

But boy does he have a point and I mean that honestly. I can totally see what he means and a certain part of me is still contemplating if I should continue this. But I really do enjoy trying to piece the information together. Is it unethical?

What do you think?

Ian Thorpe Drops Out AND Expands the Differential

2006-03-09T03:18:00.000-08:00

In a sudden and unexpected move Ian Thorpe, by far Australia’s best swimmer, has dropped out of the Commonwealth games. During training Ian, who was said to be quickly improving, was unable to complete his usual regiment, becoming winded after twelve laps. Afterwards, on national television, he announced his withdrawal from the Commonwealth games.

Previously I stated that after reading the reports issued by the press I believed that Ian Thorpe may have HIV. This was due to the following factors:

1. Ian has now been ill for more than three weeks with a “viral” syndrome and I do not believe that this is likely.

2. His coach, Alan Thompson, stated that: “The antibodies in his blood were beginning to rise”. I believe that he was referring to Ian having a certain type of immunodeficiency and by far the most likely diagnosis in his age group is HIV.

3. The Doctors and Ian himself are being extremely vague concerning what is going on and the result of his testing.

4. Ian has been placed on antibiotics for a viral condition and this is not commonly done unless the doctors are suspecting something deeper.

During his press conference Thorpe revealed that during his childhood he had to take a three month vacation from school for another bout of “viral bronchitis”. This is interesting because it hints to another diagnosis that is less likely, although possible.

Immune deficiencies are a group of disorders characterized by the dysfunction of the immune system. There are a number of disorders but each expresses itself differently depending on the specific disorder present. Although a lengthy discussion of the topic would surely not be appropriate here, you can find more specific information elsewhere.

Generally, immune deficiency would manifest as recurrent infections. However, due to Ian current age and his known health status I think that we can rule out the more malignant ones. In addition if you remember Alan Thompson, the coach for the Australian Olympic team, stated:

“He got some blood tests back today and they were positive and showed an improvement in the blood parameters and the anti-bodies are doing well"

In my earlier post I speculated that Mr. Thompson may have been misinformed and that more likely he was referring to the White blood Cell (WBC) count that is often checked on a cell count. But what if he wasn’t misinformed? What if Mr. Thompson knew exactly what he was saying?

Are there any immune deficiencies that would express themselves as a decrease in the amount of antibodies in the blood and would not present with consistent recurrent infections. I placed consistent in bold type because if Ian Thorpe was consistently ill he would not have been able to achieve all he has until now and so I believe we can assume he is healthy most of the time.

One diagnosis jumps to mind more than any other: Selective IgA Deficiency

This deficiency may be congenital or acquired (meaning people get it later in life). More importantly, it’s not altogether uncommon and many of those who have the disorder lead normal healthy lives. In addition, it is not uncommon for it to manifest as recurrent upper respiratory infections. the same condition Ian has ahd for three week now.

Ok, I admit, my bet is still on HIV. But a good differential always includes a number 2. All that’s left now is to wait for someone to leak some more information.

Go Read Grand Rounds! It's an Emergency

2006-03-08T03:10:00.000-08:00

Kim at emergiblog has this week's Grand Rounds and she's decided on an Emergency Department theme.

Future Intern: One Year Old Today

2006-03-07T03:35:00.000-08:00

Most of the readers who’ve been with me for a while know what my favorite and shortest post of all time is. It was exactly one year ago today.

I am profoundly amazed at how one year has passed so quickly and how far my little intern has come. I’m so proud of her. After all, she’s already mastered how to perform lumbar punctures and central catheters and she’s not even in medical school (Not for another three years).

Today the Future Intern, and my little girl, is one years old.

Kirby Puckett in Critical Condition

2006-03-06T07:47:00.000-08:00

Former Minnesota Twins center-fielder Kirby Puckett had a stroke at his Arizona home yesterday and was taken to a hospital for surgery, the team announced from its spring training camp. The 44-year-old Puckett, who led Minnesota to World Series titles in 1987 and 1991 and is a member of the Hall of Fame, was taken to a Scottsdale hospital where neurosurgery was performed to evacuate the bleeding in his head. Mr. Puckett is in critical condition.

This is the second famous case of hemorrhagic stroke in as many months. The most common risk factor is hypertension, which causes nearly 60% of all strokes of this type. Other causes include amyloid angiopathy, trauma, cocaine and ruptured arteriovenous malformation.

Mr. Puckett is pretty young for this type of condition. Which can make causes other than hypertension more likely. However, it is unclear is Mr. Puckett did suffer from Hypertension although his recent weight (>300 lb.) makes it likely that he did. Some of his history may suggest risky behavior and makes cocaine use likely (Although I am by no way claiming that he had).

In terms of need for surgery to evacuate hematomas. evacuation of the hematoma is generally not helpful except in cerebellar hemmorhages. Most hematomas more than 3 cm in diameter also require surgical drainage. There are other indications for surgery that include clipping of an AV malformation or placement of shunt. Regardless of the cause, the need for surgery often indicates a poorer prognosis.

More to come as information is released.

Is Ian Faking?

2006-03-06T06:46:00.000-08:00

A second differential diagnosis for Ian Thorpe:

The coach of South African swimming star Ryk Neethling has sensationally claimed Ian Thorpe's illness could be a ploy.Neethling's coach Dean Price said he had heard reports from the Australian camp before that swimmers were sick on the eve of major competition only to watch them dominate.

Thorpe is due to clash with three-time Olympian Neethling and fellow South African sprinter Roland Schoeman in the 100m freestyle.

It seems I didn't incorporate the "clashing" factor present in swimming competitions into my differential.

Now That's a Medical Miracle

2006-02-28T05:05:00.000-08:00

I am referring to having just spent two weeks in the same house as my in-laws and NOT having sent someone to the hospital in need of "trauma-surgery" STAT!

Speaking of trauma surgery (now that's a nice transition), this weeks Grand Rounds are at Cut-to-Cure, a blog who's author is a real live trauma surgeon. I didn't manage to submit, or write anything, this week. That was due to the ninety degree weather I was experiencing. Amazing how it inhibits creativity and idol time in front of a computer screen INDOORS.

While I get this thing up and running again, I demand you go and have a read.

And I wanted to thank everyone for the input on the previous post. I will try to take some of your advice and incorporated it. I am back home, grateful to the airline industry for managing to keep me out of any burning infernos.

Friday Intern Topic of the Day VI: How Can We Make This Blog Better

2006-02-23T23:16:00.000-08:00

So I would like a little constructive criticism of how I can make this thing a little more interesting.

anyone...anyone?

What?

2006-02-23T23:01:00.000-08:00

Saturday was my day off. I decided to spend part of it catching up with my brother who recently ventured off on his own and began a startup internet price engine. We spoke about the business and the general state of the market.

During the two hour conversation he told me about how "spiders” were “continually crawling his site” and “indexing pages” into the search. How he had to track “IP address” and other “browsers” to determine charges that would be incurred. This incomprehensible soup was spewing out of him like honey. Had I the guts to explain I understood but a simple portion of our initial conversation and nothing else (Specifically, when we exchanged goodbyes) I would have endured an hour long lecture. But the experience truly shocked me, the exploration of my internet age ignorance that is.

When did it get to this? We speak English mostly everywhere but even our English is divided into Spanglish, Slang and Rap. Then there's Ebonics and Spanish and in certain areas you can't get along if you don't speak the local vernacular.

I am so glad that as a part of the medical community we are not privy to these types of miscommunications, everything is plain and simple. Our vocabulary, an example of brevity and clarity.

So, the other day when a Surgery consult came to ask me to clarify what was written in the chart of a patient I had recently admitted I stared at him in sudden disbelief. Why it’s clear as night and day. The chart read, "64 y/o m was in USOH 2 d/ PTA, BIBEMS w/ c/o pain in LE and SOB, please r/o DVT/ PE. Obtain duplex, get a V/Q, D-dimer and spiral CT/ PE Protocol".

Where did this guy come from, Mars?

An oldie but goodie from the archive. Check the comment section for an explanation of the chart.