Reggie

As I stand outside the Greyhound station in downtown Cleveland, I can’t help but think how backwards the interview process seems. Here I am, staying in luxurious hotels sometimes subsidized by the hospitals, being wined and dined for dinners and fed free lunches just to find out if I am a “right fit” for program XYZ. The contrast can’t be starker as I stand outside in windy cold of December evening with my backpack and my four-wheeled suitcase in a less than glamorous part of town. Considering that much of residency is spent taking care of underinsured, non-compliant, irresponsible, and disenfranchised populations, it would make more sense for programs to introduce us to the people we would actually be serving instead of touring us around the magnificent hospitals whose ever expanding presence testify to the failure of health care in this country. Wouldn’t it make more sense to see the homeless shelters, soup kitchens, and shanties that our patients would be coming from, the crack houses, drug warehouses, and other socially unacceptable settings from which many patients would return once they left the clinic?
It seems like an awful lot of money to be spending on such a self-serving cause. A part of me would much rather learn about the cities where I might spend the next three years or learn about how I would be serving the communities around these hospitals.

And still, in the midst of the grandiose thoughts, a man calls out to me. Inside I cringe because I know what is coming. I turn around and see a black man in a black cap smoking a joint.

“Hey, did the bus just get in?”
“Yes”
“Do you know if they found a wallet?”
“They did not.”
“Can you give me some money.”
“What do you need it for?”
“So I could get something to eat. I lost my wallet.”
"Did you go inside and ask if they found it?"
"Yes, they didn't find nothing."

I loathe myself because I know I shouldn’t go down this avenue of conversation. I know I have some cash in my wallet and am not in the mood to lie. Had I thought about this more, I would have asked how he got money for that joint. Instead, the following ensues.

“Is there somewhere you could get something to eat?”
“Yeah, there’s a Subway right around the corner.”
“How much do you need?”
“Five dollars…you know they have those five dollar foot longs.”
I pause and look around for the hotel shuttle. I wished it came earlier. I walk down the street to see if I missed it. Still nothing. I turn back to him.
“What’s your name?”
“Reggie.”
“Where are you from?”
“Toledo.”
“How did you end up here?”
“I’m familiar with this area. My people brought me here. I know the food pantries around here.”
His eyes look distant. He’s probably high.

“Promise me, you’ll use this for food.”
“Yeah…of course.”

I hate myself for this comment. But in the end I give the few bucks that I have. Because of my conversation I do not notice that the hotel van has come and that the driver has actually called out for me. I get in the van.

“Didn’t you hear me?” the driver asks somewhat irritated.
“No, I didn’t. Sorry. My bad.”

But at this point my mind is already lost in thinking about my encounter with Reggie and wondering what sort of drugs he’ll use the cash for next.

Love

He was an elderly gentleman in the hospital who had a urinary tract infection w/urinary retention secondary to benign prostatic hypertrophy. Speculation on his mental intelligence aside, this man could not provide a straightforward, concise history. His wife attributed it to his history of epilepsy which certainly played some role in it. Most times his responses were vague and his reactions "child-like." The wife affirmed that in actuality, this was normal mental status for him. It became clear that his wife would be the sole source of meaningful medical information; she was his primary caretaker, the one straight-catheterizing him and measuring his urine output in milliliters. Turns out, she was a nurse for the neurosurgeons in town, though one wouldn't have needed to know that to affirm her intelligence.

Outside of the room, the attending commented on how she was a little surprised at how a woman like her would end up marrying a guy like him. "She's clearly in love with him still...it's cute," she had correctly observed, "but she's just so...intelligent"--her words not so much conveying confusion as much as they did amazement.

An FMG that Plays in Peoria

Two weeks into my inpatient medicine subinternship, I am tempted to dwell on the shortcomings of the rotation thus far. I can talk about how few patients I get to see on my own or how I have long since given up trying to impress anyone, much less my attendings. So, when I have very little good to say about myself, it's easy to think about the people that have made this rotation memorable thus far.

In the past, the patients have ruled this forum. Tonight, this honor belongs to a senior resident--not my senior resident, but the one on our sister team who I was reunited with after having her for a week on my M3 medicine rotation.

DP was a second year resident when our paths first crossed. What struck me was how assertive and forthcoming she was in both asking questions and finding answers. She was one of those self learners who would be any educator's dream. She was one of the few residents who aggressively taught the medical students anything. I still remember the first sit down session we had on EKGs with us.

She was the first person in medical school to openly espouse Wikipidia as a legitimate source of knowledge. After all, many of the medical entries were straight from Harrison's. Her advice was as follows. Whenever she found something that worked, she would keep doing it and doing it until someone told her she was doing it wrong. If said person could then explain convincingly why his or her way was better, she would be willing to change. Otherwise, she would persist in her ways. She was the first to tell me that despite what we were taught, that closed-ended questions were essential to efficiency. Ask your questions first, then let the patient have their say. Find out what's important to you as a physician first, and then let the rest of the history guide your decisions.

I realize that while her advice seemed to fly in the face of what I had been taught, it makes sense in a lot of ways as well. Especially when one is working with high volume, indigenous, low educated populations. In fact, I saw it work for her. She was not worried about making mistakes, because she was always wanting to learn from them.

Over the last couple weeks, she has shared some of her life stories, and the stories have sharpened my understanding of her. She was top 5-10% of her state in India, meaning she got free tuition. Before then, she worked as a lab assistant in the states, learning English in the process. Her husband was also in the states pursuing education but due to their limited opportunities they were often in different states. She ended up in Alabama by UAB and she told a story of how sent 170+ emails to different labs asking for an assistantship or any kind of opportunity. Of those emails, two replied and neither with good news. One of them, however, told her that her English was terrible and that her writing was chalk full of errors. The author proceeded to rewrite her letter for her and gave her a version to send out to employers.

After medical school, she applied to 180 residencies. She received 19 interviews and went to 14. The place in New York that she ended up at was, for all health care purposes, horrendous. The residents she met all had their stories about how they ended up in a dump of a residency. Many of them were tragic and undeserved for their caliber of clinician and quality of person. There was the former ER doc who was blackballed after standing by his principles to defend a clinical decision that rankled his superiors. There was another who left years as a critical care nurse to pursue his dream. Another was from the Caribbean and fully trained EKG tech who was happy just to train in the states. Every person had their story, and despite the crap she dealt with, Dipa wouldn't have traded that one year for the world.

Eventually she transferred to Peoria to join her husband. It was during the weekends on call where I would hear her stories and listen to her rants on how internal medicine was 80% social problems and 20% clinical. She would talk about ungrateful, entitled patients, lowlifes that used and manipulated the system at no disregard to cost or others. She was tired of dealing with these people and with many of them she would not hide her disgust. On one hand this seemed appalling for a doctor to act this way, but in many other ways, it was refreshing because it showed a certain degree of conviction. She was letting these patients know that she knew what they were doing and while she would still help them, she wouldn't bend to their demands.

In the end, she wants to do GI. If not that, then a hospitalist. Wherever she ends up, this I know. I will be grateful to have cross paths with her, and in many ways, I hope that I can learn to pursue my interests with as much tenacity as she has in her own life. Stories like her's make me immeasurably grateful for the opportunities I have been given; her story gives me hope that despite my deficiencies, I have been fortunate to have people such as her who have helped me to get this far.

How I learned about medicine this year

During my second year in medical school, I wrote an email to the rheumatologist with whom I spent some time during M1 year. I told her how I would more easily remember the insignificant, non-medical trivialities from my lectures rather than the testable, high yield, board-relevant material that I was spending so much time just trying to care about at times--let alone learn.

Today, as I prepare for boards, I find myself in a similar situation: fighting the urge to gloss over certain diseases, risk factors, etiologies of conditions that at times mean very little to me. Every so often I'll come across a condition that links to a friend I have, a patient I saw, or an encounter in the hospital. Myasthenia Gravis, Essential Tremors, Multiple Sclerosis are replaced with the faces of the friends and people who have played an instrumental and meaningful part in my life these last few years. For a brief moment, they become my daydream, my escape, an absence seizure from the world of medical terminology.

If you asked me about acute pancreatitis, I could not tell you Ranson's Criteria but I can tell you all about the homeless man that had it--how he was a boxer in his youth, could control his blood pressure with his mind, and how he would roam the streets at night living a life that you would only see in movies. If you were then to ask me about Meckel's Diverticulum, I could not tell you the specificity of scan to detect it (the sensitivity yes!), but I could tell you all about the anguish and cultural intricacies written all over the a Chinese mother’s face as she couldn't understand why the surgeons had performed the surgery on her son when there was no Meckel's to be found in the OR.

And so this is how it has been for much of the last year; it has seemed to me more of an experience than an education. I ask myself what exactly I did this year outside of accumulating a treasure chest of stories that I might one day dig out for the sake of good conversation.

Furthermore, in the back of my mind, I am terrified that this will not be enough--that these ruminations will be woefully inadequate for me to master the information I need to effectively convey to my future patients. I ask myself whether these reveries are but an expression of laziness that serve to convince me that I really am engaged with the material.

Having said all this I return to my letter to the rheumatologist. In her reply to me she wrote the following.

"I was always of the opinion that recall of all those meaningless trivial facts was the sure sign of a bright and inquisitive mind, one that had room for lots of stuff, not all of which came from books! I think it also means you recognize the humanity in us all, a good trait for a doctor to have! It helps to reinforce the concept that we take care of people, not just diseases, and that humanity thing is what keeps medicine interesting and relevant."

Looking back at her words, I take hope in the larger picture. For I am neither naive enough to believe that a better academic performance would have proved a greater personal dedication to my craft nor am I delusional enough to think that every mistake I've made is simply a product of a bright and inquisitive mind emerging from the chaos that is medical education.

The reason why I got into this was because of the people I met along the way. As much as I conceptualized what medicine should look like, the only reason why I am still in school is because of the people who showed me what medicine could look like. In the end, the latter is what I have to hold on to for now. With each new experience stones will shift, clouds will clear, and visions will change. That is to be expected.

For now, the words of my high school Spanish teacher ring through and through
"Lo que sera, sera..."

The Problem With Hipaa

From a patient care point of view HIPAA preserves the privacy of those within the health care system. It is necessary given the sensitive nature of the medical profession. For a physician, patient privacy is intertwined with the trust that is essential in the patient-physician relationship.

At the same time, HIPAA robs the patient of his or her identity. Violia Freeland becomes VF or "63 year old Caucasian female" when I try to describe her to someone else. The absence of the name reduces the subject into a collection of symptoms and attributes, many of which aren't particularly unique, but all of which together, forms a unique narrative and a special individual. It is within a person's name that everything becomes attached- chief complaint, history of presenting illness, past medical history, social history--all of this becomes significant because they comprise parts of this person's narrative. This is why the name is important; because without it, I must try to make sense of a faceless entity. Perhaps this is why so many medical students like reading cases instead of textbooks because instead of an outline of factoids, we are reading a vignette, a discussion about a story, how this story relates to others (a differential diagnosis) and a treatment that pertains to this specific case.

As this M3 year draws to a close, I find myself thinking about the many patients I came across throughout the year. I realize that there are many patients that simply became faces in a sea of daily activity and yet there are others whose names and stories will remain with me for quite some time. It comes to me as no surprise that I often have names to attach to the latter. This isn't to say that the former were insignificant experiences--there is still much value in them yet--but when it comes down to the core of medicine, I believe that there is a significance to beginning with a name, a face, a history before the physical. While the lab work and imaging studies receive much of the attention, money, and publicity when it comes to health care, I have to remind myself that the reason why I decided to stick it out this past year was because I hope to one day assist the Leonard Andersons, William Hartwigs, and Suzanne Bowens, to continue living their lives, no matter how long or short their narratives may be.

Inpatient Medicine

In the morning, we round on patients and monitor their progress. In the afternoon, we make phone calls to track down patient records, call primary care physician offices to schedule follow-up appointments, update other physicians on the progress of their patients, and on top of that try to deal with the myriad of social issues that inevitably arise with our patients. In the morning, we do what most people would imagine a doctor to do. In the afternoon, we do all the crucial busywork in an attempt to ensure some form of lasting continuity to whatever clinical improvement is made during a patient's stay at the hospital.

The term that keeps coming up in the hospital in reference to some of our patients is the word "babysitting." We make calls to their doctors when they should be doing it themselves. We repeatedly try to convince them to take their insulin when they complain they don't like getting shots to prevent one or more of the innumerable consequences of diabetes. For all the complexity that goes into learning about obscure diseases and the latest evidence based medicine, playing the social game is often just as difficult and a hundred times more draining.

It would be easy to blame all of this on patient lack of education, but the reality is that the messiness extends to all levels of society. Richer people may be more knowledgeable and compliant (and even this isn't a guarantee), but this does not always guarantee gratefulness or the ability to cope with dire circumstances. The mix of uncertainty, anger and denial will make the most educated person irrational--and all it takes an already stressed-out intern or jaded senior resident to turn a normally workable situation into an intolerable one.

It is this afternoon work that often drives many residents to do everything they can to avoid the social mess that is the modern health care system and pursue careers in outpatient specialties or more surgically oriented fellowships. After all, why should one go 200K in debt to subject him or herself to rude patients, patient who won't take their medications, chronic drug abusers who abuse the health care system as much as they abuse the drugs, and have to spend hours calling hospitals just to track down some test that was done 5 years ago that may not even end up being useful in the end? Why wouldn't you want to go into a field where you can dictate the patients you see and only have to deal with patients who actually want to see you?

Inpatient medicine is not merely Patient X has Disease Y that must be diagnosed by test Z and treated by drug 1 or Surgery 2.

No, it is much more often Patient X with disease Y will not take Drug Z for his condition Q which causes him to come into the hospital with complications A,B, and C leading to hospital stays that require expensive testing 1,2,3 that are ultimately paid by the taxpayer because Patient X is on Medicare or unemployment.

Refeeding Syndrome

It was the second time they went to go see him. It was the wing of the hospital furthest from the main building, the Forest, they liked to call it. He had a lot of problems. Cancer, fungus in his blood, cystic fibrosis, and probably a multitude of other opportunistic infections. The attending followed by the intern followed by the medical student. They were the infectious disease team consulted by the primary service to manage something.

"You look a little tired today," the attending said, dressed in the yellow isolation gown.

No response. He was known for not always being particularly responsive.

"Are you having trouble breathing?" He clearly was, but was still capable of speaking. He looked at them blankly and annoyed. The physician looked at him concerned.

The intern coming up along the bedside took a brief glance at the patient. With a quizzical look on his face he turned to his attending and remarked, " I think he might have refeeding syndrome. Sometimes after people haven't eaten for a while, their body has a hard time readjusting to oral intake creating increased carbon diox--"

"Listen to me," the emaciated 25 year had spoken. His hoarse, weak voice conveying the severity of his condition.

"The reason why I'm tired is because I can't sleep. Every night I have nurses that come in a readjust this and readjust that. I'm in pain. When I finally do fall asleep, I'm woken up again at 4:30 am so they can draw blood. Then for some reason, when the nurse comes in to get my blood, the other nurses think it's a good time to come in and take my blood pressure, take my temperature. Next thing I know some doctor is coming in at 6:00 am to ask me questions. Now it's bright out. Then when everyone finally leaves me alone you guys come along and ask me even more questions, see me tired, and think I have some refeeding syndrome. Now I don't claim to know as much as you doctors with all your knowledge and training, but what I do know is that if I could actually get some sleep here, I might not be so tired when you guys come around. What I do know is that I don't have no refeeding syndrome"

Silence blanketed the room. The attending turned to the intern, "I don't know why they have to draw blood at 4:30 in the morning. We'll try to stop by earlier in the morning so that he won't be interrupted as much."

And wishing the patient well, they turned around and left the room leaving the sick man to attempt sleep once more.

Hypernatremia w/altered mental status

He actually wasn't conscious when he first came in--of this we were aware. He came in last night, but that morning we met him as a team. Mouth perpetually wide open, hands wrapped in giant mittens to protect himself and others around him.

"Mister Griswolllld!" Our senior resident would yell out each morning shaking him by the shoulders. That morning he responded with unintelligible moans.

My intern whispered in my ear, "Hey Griswold. Where do you think you're gonna put a tree that big? Bend over and I'll show you!"

"You ever seen National Lampoon's Christmas?" he asked me.
"Parts of it, but never the whole thing"
"Alright. Your assignment for today is to watch some you tube clips of that movie so we have something to laugh about together."

Over the next week, Mr. Griswold would recover some form of responsiveness. Demented as hell, each morning he would be greeted and shaken. Eventually, the mittens came off when he was aware enough to stop scratching himself and pulling out his IVs. Then we noticed his hands.

"Hey, check out his lobster claw!"

His left hand sprouted three long and sinewy fingers and nothing more. The thumb, the index, and the bird.

"Watch out. Once he gets a hold of your arm, we'll have to chop it off cause you ain't getting it back!"

Those first few days we couldn't understand a word he said. Then, one morning, I went in with my senior for our daily shaking. He was already awake by the time we got there. Eyes open, he stared at us. We paused, startled at his consciousness. His ever gaping mouth slowly curling upwards, eyes fixed on her.
And then he uttered.

"IIII LUUUUV YOUUUUUU!"

"Awwwww" the inflection in her voice crescendoing as we left the room. "He said he loved me! Mr. Griswold!"

The last day I saw him we were planning him for discharge. Several steps from his room we smelled it. Clostridium Dificile. Shit. Literally.

"How you can tell it's C. Diff?" I asked.
"Just lift up his sheets and smell it."

And so he and his lobster claw were discharged from our service likely to relapse as soon as he settled into the nursing facility to which he was going, We had all come to see Mr. Griswold in a certain light. From unconscious, dehydrated admit to helpless, feces-ridden geriatric to lobster claw freak show, it's startling how little we actually knew about him.

"I loved Mr. Griswold," our senior mused.
"That's because he told you he loved you!" one of the interns replied.
"I know..."
"But he never seemed like the sort of guy that would have a history of being arrested several times for robberies."
"Oh, Mr. Griswold."

An Interesting Case

"Go meet Dr. Patel in clinic. She's seeing a patient of mine that I think would be good for learning. We're trying to decide whether she has acute or latent TB."

This is what he had been told, and like a good medical student one week into the medicine rotation, he scampered outside, through the snow, and up the stairs to the doors of the clinic.

"Dr. Patel's already in with the patient."

So down the hall and opening the door on his left he slid into a rather small room where the patient was seated in conversation with Dr. Patel.

Dr. Patel was gathering history. Have you any night sweats? fever? weight loss? hemoptysis? No, none of that, she said. She had had a hard life. Extensive medical history compounded by the common American co-morbidities. Any imaging? She thought she had some, but couldn't remember. On and on the history taking went. He picked up her medical records and glanced through them as the chatter continued.

Extensive psychiatric history. Well, given her history, who could blame her?

What did she do for a living again? Disability now, entrepreneur or something like that. They all failed though, her businesses. What were her businesses? He didn't ask.

She had been possibly been exposed to TB when she was a nursing student in the past.

Wait. What?

And then it clicked. He had seen this woman before. She did not recognize him. His memory stirred. Where?

The Ward.

She had wanted to kill herself. She was much more upset back then. He had tried to ask her about her history. She had snapped at him. Too many questions. Why did he want to know? She had left the ward and was supposed to go home but had disappeared according to police reports. That had been the last time he heard of her.

But here she was now. Sharing bits and pieces of a history not so unfamiliar. More psychiatric than medical in some ways, and more human than anything else.

Her most recent imaging turned out to be quite unremarkable. Disappointing from a medical standpoint. She would need further testing and there was no point in risking medication side effects when she was completely asymptomatic and without proper supportive imaging.

Walking back to the hospital, he thought about what she had told him before he left the room. She had told him that he would be a good doctor.

"You have a certain way about you, how you conduct yourself."

Really? Is that all there is to it? He had thought to himself. She didn't know him--just like he didn't really know her. The absurdity.

And then he remembered that this was supposed to be an interesting case. It had been, but not in the sense that he had expected--not medically or in a psychiatric dimension. He couldn't quite put his finger on how it was, and it bothered him. Another time, he would have to revisit it. Perhaps it would make sense then. In the meantime, another morning case presentation. 54 year old woman with a history of diabetes, hypertension, hyperlipidemia presenting with chest pain...