Saturday, August 20, 2005

I don't have to study!

Took my boards yesterday so I actually don't have to study today. I haven't had a Saturday with nothing to do in forever, I almost don't know what to do with myself. Almost... but I think I'll just laze around reading and watching The Comeback.

Thursday, August 18, 2005

Step 2

Well, the day is almost upon me... I take my boards tomorrow. I'm so nervous I feel physically ill. I keep trying to calm down but then I remember that my whole future is relying on this test. My score will help determine which residencies invite me for interviews and will ultimately play a role in how they rank me. I know that I'm not the Harvard ir Hopkins type, don't even want to be, but I would like to end up at the program of my choice. So I sit here dreading this test.

I've been studying for almost 2 months, but hard core for only the past 3 weeks or so. I've read the review books and done plenty of practice questions, but I just don't feel ready. The questions that I'm getting wrong are about things I've never even heard of, so I don't really know what else to study. The Kaplan people say that getting 70% on their review questions will put you "well above the mean" but I just don't know. My average is there, but I have wild swings from 62-84. Those low scores don't make me feel any better.

I know that it's important to have some sort of standardized test in order to compare people from different schools, but it just puts so much pressure on. It's like the SAT and the MCAT -- the questions are strange and often irrelivent but you feel like your life depends on them. I wish there was some other way to compare us. We all take the same basic rotations and get letters from out attendings; can't they just read those. Will this test show that I can work up a patient and manage his care? I really don't think so.

Several more hours of daylight before I try to get some much needed sleep. Gotta do some more studying and then I'll watch some Horatio Hornblower to calm my nerves. Ioan Gruffudd is excellent at that :)

Tuesday, August 16, 2005

Thank you for educating me.

I think this letter should be distributed to everyone in a teaching hospital.
Thank you for letting me shine bright lights into your eyes and place Q-tips up your nose. Thank you for not shooting me a dirty look when I ask you to lift up your pendulous breast so I can listen to your heart. Thank you for letting me ogle at your protuberant belly—whether it contains a baby, a liver tumor, or liters of fluid inside. Thank you for not experiencing an erection and for refraining from snide remarks when I examine your penis. Thank you for telling me that my speculum use is suboptimal and has caused you pain during your pelvic exam. Thank you for nearly kicking me in the face when I tap on your knees to test your reflexes. Thank you for peeing all over me after I remove your diaper...
Thank you for calling me “doctor” when I don’t feel like one at all. Thank you for saying “thank you” when you’re getting better—in spite of me, not because of me. Thank you for poking fun at me for the express purpose of making me laugh. Thank you for giving me a hug before you leave the hospital. Thank you for smiling at me.

Grand Rounds 47

This week's Grand Rounds are up over at Circadiana.

Monday, August 15, 2005


This recipe from Glad Gastronome sounds awesome. I think I'll whip it up this weekend and then use it to cheer up after failing the boards.
From James Beard's American Cookery. This definitely has a zing from all that ginger.

2 eggs
3/4 cup firmly packed brown sugar
3/4 cup molasses
3/4 cup melted butter
2-1/2 cups sifted all-purpose flour
1 teaspoon baking soda
1 teaspoon baking powder
1/2 teaspoon salt
1-1/2 to 2 teaspoons ginger (I used 2 t.)
1/2 - 1 teaspoon cloves (I used 1/2 t.)
1/2 teaspoon nutmeg
1 cup boiling water

In a mixing bowl, beat the eggs and then beat in the sugar and molasses until very fluffy (easiest with electric mixer). Stir in the melted butter. Sift the dry ingredients together and stir into the first mixture. Add the boiling water and stir just to mix. Turn into a well-greased sheet pan about 10 x 14 x 2 inches (I used a standard 9 x 13" pan and it worked just fine). Bake in a preheated 350 degree oven about 35 minutes or until the cake springs back when pressed lightly in the center. Serve hot or cold, plain or topped with a fruit or chocolate sauce, whipped cream, or ice cream.

From The Cake Mix Doctor. There is not a bad frosting recipe in this book. They are all homemade as opposed to the cake recipes which fix up cake mixes. I don't use the cake recipes from this, preferring the texture of home made cake, but I do use it for inspirations on cake/frosting pairings.

8 tablespoons (1 stick) butter at room temperature
3-3/4 cups confectioners' sugar, sifted
3-4 tablespoons milk
2 teaspoons pure vanilla extract

Place the butter in a large mixing bowl. Blend with an electric mixer on low speed until fluffy, 30 seconds. Stop the machine and add the confectioners' sugar, 3 tablespoons of milk, and vanilla. Blend with the mixer on low speed until the sugar is incorporated, 1 minute. Increase the speed to medium and beat until light and fluffy, 1 minutes more. Blend in up to 1 tablespoon milk if the frosting seems too stiff.

Sunday, August 14, 2005

Movie Review: Look at Me

I've been on an independent/foreign film kick lately, so I decided to check out Look at Me, a film about a famous author and his daughter. Etienne is so wrapped up in his own fame that he completely ignores his daughter Lolita who tries desprately to gain his affection. The little attention he does show her is to comment on her weight by pinching her side and calling her "my big girl." By the end of the movie I wanted to slug him. The more interesting relationship in the movie is between Lolita and Sebastien. Sebastien likes Lolita and tries to get close to her, but she is so focused on her father that she drives him away. And then accuses him of using her to get to know her famous father, as so many have done in the past. Through the movie you can see Sebastien get frustrated with Lolita and want to just give up on her. A great movie with what I've come to expect from these independent films -- an ending 5 minutes too soon. It's like they make the movie and then chop off the conclusion that tied up all the loose ends because they want the audience to be free to imagine their own ending. But I'm paying you to tell me a story, so finish it, damnit!

Lolita: I'm hopeless!
Sebastien: We all are.
Lolita: Yes, but me more than others.

"Many find the job of being a modern patient, with its slog through medical uncertainty, to be lonely, frightening and overwhelming."

At last, inspiration strikes for my ERAS personal statement. An article in the NY Times discusses the challanges facing modern patients. In the move away from paternalism doctors no longer tell patients, "This is what's wrong and here's what we're going to do about it." Instead patients are presented with a diagnosis along with a list of treatment options. Coronary artery disease? Bypass, stent, or medical managment. Lung cancer? Surgery, radiation, chemotherapy, or palliative care. Patients are left to weed through vast amounts of imformation trying to weigh the pros and cons of each options without the background knowledge that 4 years of medical school and 3 or more years of residency provide. Doctors often try to offer treatment options without showing bias toward one or another to prevent detracting from patient autonomy. And the fear of lawsuits makes it more appealling to not give a definite answer. Give all the options and let the patient decide -- you can't get sued for that. And with primary care doctors having to see more patients in order to pay the bills, they are left with little time to sit with an individual and explain different treatments and answer questions. Add it all up and you have patients who have to rely on internet searches and various doctors' opinions and then manage their own care.
"You can get good health care," Ms. Gaines said. "But there isn't good relay, getting you to the resources and the resources to you." She meets with panicky, bewildered patients and occasionally shares with them her story, if only to make one point: "I tell patients all the time: 'I know this is hard to believe, but you want to know who is managing your health care? It's you or no one.' "

After over 3 years of medical school I've decided to become a member of the ever diminishing minority -- I'm going into primary care. I hope that I maintain that through my residency. I want to be a doctor who takes the time to get a complete history and talk with my patients. I want to offer them advice about current treatments and point them toward reliable resources. I want to make thoughtful referrals to specialists and help my patients get through the maze of modern healthcare.

Thursday, August 11, 2005


The Dallas News decides to call a terrorist a terrorist. It only every news organization was so logical.
Today, this editorial board resolves to sacrifice another word – "insurgent" – on the altar of precise language. No longer will we refer to suicide bombers or anyone else in Iraq who targets and kills children and other innocent civilians as "insurgents."

The notion that these murderers in any way are nobly rising up against a sitting government in a principled fight for freedom has become, on its face, absurd. If they ever held a moral high ground, they sacrificed it weeks ago, when they turned their focus from U.S. troops to Iraqi men, women and now children going about their daily lives.

Words have meanings. Whether too timid, sensitive or "open-minded," we've resisted drawing a direct line between homicidal bombers everywhere else in the world and the ones who blow up Iraqi civilians or behead aid workers.

No more. To call them "insurgents" insults every legitimate insurgency in modern history. They are terrorists.

Monday, August 08, 2005

Send a Sister

Send someone a nun e-card. You even get to pick the order.

So I've been having chest pain...

The beginning of almost every patient encounter that I have since starting my cardiology rotation. My favorite of the day was a walk-in. A man who has been seen by several of the partners during hospitalizations but has never followed up in the office. He has chronic shortness of breath (possibly due to his 2ppd smoking habit) but starting have some chest pain last week. It got so bad that on Friday he paid a visit to the ER. His description is not exactly the picture of cardiac pain -- sharp, associated with eating, not related to activity. So he goes to the ER and gets worked up -- EKG, cardiac enzymes, chest X-ray -- and is discharged several hours later with a diagnosis of non-cardiac chest pain. Not satisfied, he shows up at the office this morning demanding to be seen. After speaking with him, examining him, getting an EKG, and reviewing his labs we agreed that his pain is not cardiac. Talk about a waste of time. When did people start automatically disbelieving anything they are told by a non-specialist. "My family doctor thinks my cholesterol is high and I should take Zocor, but I wanted to check with a specialist." People, your family doctor went to medical school, completed a residency, and is perfectly capable to handling high cholesterol! Sorry, end of rant.

All hail the General Lee

Just got back from seeing The Dukes of Hazzard, and I have to admit that I really liked it. Not exatly high-brow cinema, but enjoyable anyway. Sometimes you don't want to have to think at the movies, and this flick is just a good time. Plenty of humor, cheesy jokes courtesy of Willie Nelson, and great car chases. And Sean William Scott is adorable as Bo Duke. Johnny Knowville was disapointing esp in his oft failing Southern accent, but I'll forgive him. Seeing the General Lee fly through the air playing "Dixie" makes it all worth while.

Wednesday, August 03, 2005

Grand Rounds 45

This week's grand rounds it up at Alois MD.

Monday, August 01, 2005

Sometimes being a doctor means... doing nothing?

As a fourth year student I get to spend my time doing electives. A nice change from being pushed from one required rotation to the next. I've spent the past month in Developmental and Behavioral Pediatrics or, as one of my attendings put it, "seeing the kids that no one else wants to see." I spent my days seeing kids with behavior problems like Oppositional Defiant Disorder, ADHD, anxiety as well as the kids with developmental delays. I've seen more crazy syndromes than I knew existed -- the more common ones like autism, Asperger, and Downs, and then some like velo-cardio-facial syndrome, fatty acids metabolism disorders, and Retts. I even saw 2 cases of selective mutism -- that's right, 2 kids who only speak to their immediate family and no one else. Can you imagine being a teacher and having that kid in your class?

I decided to do this rotation because I've worked as an Applied Behavior Analysis (ABA) therapist for autistic children and loved it. The kids were amazing and it was so rewarding to see them progress from nonverbal and withdrawn to having words and playing with toys and other people. I was so impressed and thought it would be amazing to work with these kids every day and champion their cause. But actually being in the office was so different. Often there is nothing to do for these children and little to offer their parents. Prescribing meds to improve attention and aggression doesn't solve their problems. The doc I was shadowing put it best -- "We don't cure, we treat." So true and so sad.

On my last day of the rotation I met a 5 year old boy who has never spoken. He has muscle weakness, exaggerated reflexes, an abnormal MRI of his brain, and severe developmental delay. When speaking to his mom she said she considered cancelling the appointment because there was nothing new for her to do. He's in all the therapies that are available but is making little progress. He doesn't even have a diagnosis. What words of advice and encouragement was she given -- we'll keep looking and try to find out what is causing his delays. How does that give her strength? How does that help her little boy's functioning? How does that provide for his future? I just wish we could have given her more. But sometimes we are left with nothing more than sympathy and kind gestures.

A frightening ruling

I'm not usually one to scream about slippery slopes, but this sure seems like one to me. A British high court have rules that doctors can refuse to provide food and hydration.
THE high court ruled today doctors do have the power to withdraw food and drink from terminally ill patients - even if it is against their wishes.

The General Medical Council (GMC) was appealing against a previous ruling that gave Lesley Burke - who suffers from a degenerative brain condition - the right to insist on nutrition during the final stages of his illness.

Mr Burke, 45, won the original ruling last year and it was hailed as a landmark by groups representing the terminally ill.

But today a panel of three judges headed by Master of the Rolls Lord Phillips set aside the decision.

I have read about this sort of case in the past, esp in regards to NICU babies, but I just assumed that the courts would be reasonable. I have no problem with patients or their families choosing to stop nutrition in terminal patients, but that should be a choice for them to make. To give doctors that decision stinks of paternalism. And it occuring in the UK makes me suspect that there is some regard to the cost involved. One more reason to avoid socialized medicine... when the government pays for all medical care they get to decide what is necessary.