It Is What It Is...

Done w/ i-med. Been there, done that, and got the vomit stains on my jacket to prove it.

Had a very strange en-masse exit interview with the aging program director and five other med students. Funny how different people perceive a situation in very different ways. I left the hospital with basically a neutral and more or less happy impression, having learned some good stuff, met some good people, endured quite a few indifferent and/or lazy people, survived one death threat and one attempted mugging, and found it all basically par for the course.

Of the five other students in the room, two were also sort of neutral about the experience, two were barking pissed off, and one claimed to have had an ecstatically good time that kind of left everybody else in the room with their eyebrows raised.

I don't think it's a coincidence that the three of us who found the experience more or less neutral all had paying jobs doing something or other before coming to med school. My hypothesis is that if you've worked for a living, you know that "baseline" for most people in most jobs means taking a lot of shite along with whatever satisfaction the job might bring. Anything better is icing on the cake, and that icing is usually what you scrape together for yourself.

Going right to med school out of college that may not be so clear. Thinking about myself at that same age, especially considering the school I came from, I also had expectations of the world that were not all that realistic. Nothing wrong with ideals, unless you're shocked that other people don't share them. And they almost never do.

So I was a little embarassed for my two classmates who were kind of screaming at this aging doctor who is the program director at this hospital (even though his stories about monkeys in Costa Rica really were of questionable relevance to our education...) I was wondering, have these people never been in a crappy situation before? Really?

As for the ecstatic kid, I'm not sure what his deal was. I think he was actually sincere. Or maybe he got into the pharmaceutical locker.

Round Ten: Cardiology. Should be a kick.

The Limits of Compassion

Since beginning work on the wards last June, I have been dreading two inevitable occurrances. One: having a patient die under my care. Two: having a patient that I am not able to work with, to the extent that I have to sign off the case.

Number Two happened today (in the literal and figurative meanings of the phrase :)

From what I've been told, these things are inevitable, and more or less a matter of luck and numbers. Work with enough patients, and it's bound to happen. You're not supposed to take this personally, and I'm trying not to. Here's hoping that after a few hours at the gym and a nice stiff mochachino, I'll be successful at that.

This particular case ended with a rather unfortunate and unstable patient making bodily threats against me, that, considering her history, were simultaneously very funny and very scary. (It would make more sense if I could explain that history, but for privacy reasons I'm going to resist that urge and not get into the details.)

In general terms, I'll just say that whatever her motivation, the patient was angling for a certain diagnosis, a diagnosis that was not in any way medically supported. During the five days of her hospitalization, tens (if not hundreds) of thousands of dollars in tests were conducted, and the nursing staff was put through the wringer by this patients' nonstop antics.

By about day two of five it was starting to become clear that this patient might have an agenda other than getting well. The attending, residents, and nurses on the team had mixed reactions, from outright anger to guarded compassion. In any case, we were still obligated to meet the "standard of care" and run every possible test to rule out the condition in question. We did that.

As for my reaction to the patient during these five days, it at least began on the compassionate end of the spectrum. I think that first started to be strained on the afternoon when I was present in the patient's room when a friend came to visit her. As I was taking the blood pressure cuff off that patient's arm and getting ready to leave, she told her friend that we'd made a certain diagnosis. The patient knew at that point we'd definitively ruled that diagnosis out.

It was awkward, to say the least, for me to hear this because the patient knew I could hear her and we both knew the diagnosis had been ruled out. I'd like to think that even when I had decided in the logical part of my brain that the woman did not and could not have the disease she was insisting she had, I treated her with the compassion and respect any human being deserves.

I'm not sure that's completely true. Besides being present during the above exchange, I was also in the somewhat awkward position of hearing the frequent (but confidential) cries of "bullshit" from the attending and residents but still having to be present and respectful at the point of care. Realistically, there were probably moments when I did not live up to my good intentions.

The situation came to a head this afternoon. The results of the "definitive" test for the condition in question had just come in, and I called the two attendings involved to inform them of those results and ask how they wanted to handle things. As it turned out, one of the staff docs wanted the patient out of the hospital, ASAP, and asked me to start writing up the discharge papers. The other doc was hesitant, not so much about the results, but about how to handle the discharge without a knock-down, drag-out confrontation that might end in all of us being dragged into court, as this patient was tangentially employed by the healthcare system that owned the hospital, and, right or wrong, quite capable of kicking up a lot of dust. (As a matter of interest and record, most cases where it is later proved that a patient faked an illness involve people employed in the healthcare field.)

Apparently, the patient overheard parts of this phonecall and went into a rage. Shortly after I put down the phone, one of the unit nurses came by to inform me that the patient had made some very specific, and what at the time seemed rather funny threats against me.

A few minutes passed while I waited for the hesitating doc to call me back and the threat started to seem less funny. Even though this patient was not what you would call athletic, and I am in fairly good shape and recently managed to shake off a guy who tried to mug me in a parking lot, something about the overall behavior of this patient scared me. It scared me way down in the lizard part of my brain where logic just doesn't prevail.

I wrote everything down in the chart, had the nurse who had conveyed the threat witness it, and went downstairs to tell the resident and the attending. They agreed that things with this woman had gone too far.

In an odd way, we were all a little relieved: by making these threats, and being dumb enough to do it in front of a reliable witness, the woman had just given us carte blanche to hand her her walking papers and wheel her out the door. The nurses actually gave a little cheer on hearing their not-so-happy time with this person was coming to a definite end.

As for me, after being formally relieved of this person's care, I had the rare treat of leaving the hospital while it was still light out, and that made me very happy. Still, the whole situation makes me a kind of sad. I really do hope that it's in God's plan for that woman to find some peace. On the other hand, I'm selfish enough to hope I'm not involved in that plan.

Scutwork Revisited

I am still a year away from possessing the title Doctor. However, with nine and one half months of rotations now under my belt, if there is one thing I now feel qualified to comment on, it is Scutwork. I will begin by saying that although the term Scutwork may come across as completely negative, to say that there is nothing of value in Scutwork would be incorrect.

As with most things, Scutwork is, in and of itself, neither good nor bad. It just is, and it just has to be done. And if you are a third year med student, it just has to be done by you.

Ok, so maybe it is painfully obvious that I stood two calls this week and am on the hook again tomorrow (Saturday). Oddly enough, I am not really all that resentful regarding my current work hours. Just resigned. And given the experience I now possess, I can say with some degree of confidence that even though I'm maxed out, this rotation is one of the better ones I have been on.

So I suppose what brought the topic of Scutwork to mind was a random encounter I had this afternoon, in the corridor of the generic med school I attend, with a friend who is in the class behind mine and who just set up her schedule for next year. It went something like this: Friend (wide eyed and painfully eager): Hey, I just signed up to do my XYZ rotation at PQR Hospital. I heard you were there. What can you tell me?

Me (sixty four hours into my eighty hour week, clutching a Diet Coke in one hand and a coffee in the other): Get out now. Or run away and join the French Foreign Legion.

Friend: Really? But that hospital has a great reputation.

Me: Yeah, and well they should--they spend all their money on PR. That swanky pen you're holding is all you'll ever get out of them.

Friend: So you mean, they'll kill me with scutwork? Was it the worst schedule you ever had?

Me: No, they didn't kill me. And no, not the worst schedule.

Friend: What, then?

Me (struggling to put into words the bag full of anger I had about this hospital, that I didn't know I had, until my friend asked me about it): Oh man, just don't go there.

So I got to spend the rest of the afternoon trying to figure out why, two months after I left that place, I had this unexpectedly vehement reaction to being asked about it. This is the conclusion I came to: the massive amount of *@it work I put in during that month was in no way balanced by the minimal amount I learned during that time. I was too dumb to know it then, but I do now.

Third year, is , some ways, a psuedo-economic deal you strike at each rotation site: I will provide X-amount of slave labor, and in return, you will provide Y-quantity of learning.

Sometimes scutwork itself is enlightening, but not always.

Some rotation sites are "honest brokers" in that there is a lot of teaching built into the schedule, and you will get a fair deal just by showing up and working hard, without every being forced to haggle for your enlightenment. (Enlightenment which you are also paying the yearly equivenlent of a luxury sedan to attain.)

At other places, it becomes painfully obvious that med students are nothing more than calculated components of somebody's business plan, and that the plan doesn't include teaching those white coat wearing revenue generators much of anything.

A student who takes a totally negative attitude toward scutwork is headed for trouble and disappointment. It is a simple fact of life that somebody has to copy down lab results, make calls to welfare agencies, and sometimes, lift huge patients on and off stinky bedpans.

I actually don't mind doing these things, most of the time. I've been a patient my fair share of times, and I know that when you are on your back and helpless, the last thing you want to deal with is a resentful, snarling medical staff. When this personal logic fails, I try to remind myself that the huge person who has to be lifted off the bedpan is probably somebody's grandmother. (Although my grandmother is not huge and stinky, if she were, I'd still want somebody taking good care of her, and not be giving her a lot of attitude about it. )

When even that fails, I corner the local resident (in the nicest way possible...yeah right) and subtly remind them that in exchange for the amount of grief I am taking off their hands, I should be getting some amount of teaching in exchange. Most of places and most residents do allow for some degree of negotiation regarding the balance between indentured servitude and learning.

As for my friend, who got an earful that she was not expecting, she had the good/bad/random luck to tap me on the shoulder on a day where all remnants of my (not too diplomatic on the best of days) conversational tact had been fully eroded. So regarding Hospital X, what I had not even admitted to myself just came flying out: they took advantage of me, and of all the other students who rotate through there.

They make cavegirl mad, and cavegirl not forget...