How many controlled substances can you name?

I was at work the other night, and a mom brought in a prescription for one of her kids from an area hospital. Apparently, the kid had just been released from the hospital after breaking multiple bones in a car accident. As a result, she was getting the usual sorts of meds you'd see in this situation - Lovenox (for clot prevention), high-end pain medications (Oxycontin, etc.), Senna (for the constipation caused by the pain meds), and there was also a script for Diazepam (Valium) - likely for muscle spasms and/or anxiety.

We had 2 different doctors writing these scripts. One doctor wrote for the Oxycontin and immediate-release oxycodone - and he did a great job making those scripts fillable. He signed his name, printed his name, *and* added his DEA number to the script. *tosses confetti* Thank you for doing a wonderful job, doctor, and making my life easier!

The other scripts were written by what turned out to be a resident, after I did some research. So far as I could tell, he didn't have a DEA number, which meant that I couldn't fill the script for Diazepam. I called the hospital - they didn't have a DEA number on record, but they gave me his pager number. I paged him twice, but - of course - by this time it was getting later in the evening, so he didn't respond.

The mom ended up getting a different doctor in the department on the phone, and handed me her cell phone. Usually, I'm not a fan of talking on patient cell phones, but I just wanted to get this handled and get Mom on her way. Here's about how that conversation went ...

Me: So would you be okay with my using you as the authorizing doctor for the Diazepam?
MD: Why?
Me: Because you have a valid DEA number.
MD: You don't need a DEA number for Diazepam.
Me: Yes, you do. It's a controlled substance.
MD: Are you sure? (No, doc, I just am bothering you after 8pm because I wanted to check with what you thought.)
Me: Yes, it's a benzodiazepine. All of those are controlled. I believe they're Schedule IV. (I then quickly look it up in my computer to confirm.) Yes, sir, it's a Schedule IV drug, and I need a doctor with a DEA number to write for this drug.
MD: Yeah, fine, I'll authorize it.

And, from there, he gave me his DEA number - even though he couldn't really remember it and only gave me the two letters and 6 of the numbers. Still, he was in my computer system, so I was able to look it (and him) up.

I guess my question is regarding how much doctors learn about controlled substances in school - or was this doctor (who I don't know personally) just older and perhaps more out of touch with what drugs are controlled? I know that I had to take a law exam, which covers this sort of material, in order to become licensed as a pharmacist. This is something that I figured doctors would know.

Are there some odd-ball controlled substances? Absolutely! Pseudoephedrine-products, for one. Lyrica (Pregabalin) is another one since a similar drug (Gabapantin / Neurontin) is not controlled. But I figured that it was common knowledge among doctors that benzodiazepines were all controlled drugs. Am I missing something here?

Reason #67 Why I Love Stephen Colbert

I never knew Colbert was such a grammar Nazi, but it's nice to know he's all about the Oxford commma, too. Watch the awesomeness (starts around 2:40):

The Colbert Report	Mon - Thurs 11:30pm / 10:30c
Vampire Weekend
www.colbertnation.com
Colbert Report Full Episodes Political Humor Fox News

(I know this isn't medical-related or anything, but it's AWESOME, so I'm okay with it.)

New adventures

What with all the studying involved in Med School, one thing I've had to do is find new places to study. I've never had much success with serious studying at home, mostly because I get too distracted, I think. And usually I've just camped out at the library, which works out pretty good. The Health Sciences Library is in the same building where I've had all my classes and it's a nice, new library with good computers, so it's been pretty convenient.

But now I'm deep into studying for Step 1 Boards, which is a whole other ballgame. I've still been spending time at the library, but seeing as I don't have lectures to go to, I'm spending almost the entire day at the library, instead of just a few hours after class. So it's beginning to get a bit old, being in the same place *all the time*.

The library is closed today for Memorial Day, so I took this chance to try a new place to study. I'm at Panera, which is working out okay so far, but I'm not really sure I'm the "coffeehouse studying" kind of person. So I present to you, a list of the reasons I'll probably always be a library studier:

1. I always feel guilty, sitting at a table for hours. Even though I make a point to buy something when I first come in (coffee and a pastry, today), it doesn't really take me that long to eat those things, so then I'm just sitting at the table. And Panera makes you read this little note before you sign onto their WiFi, basically telling you not to hog the big tables when they are busy. But, of course, the only tables that are near outlets are larger, plus I have a lot of books to spread out, so here I am at a bigger table. So far it's been pretty quiet, so I don't feel too guilty yet, but when the Lunch crowd shows up, I might end up moving.

1a. Panera is stingy with their internet. I got kicked off after a half hour during "peak hours" (noon-ish), which is lame. It wasn't even really that busy, so it's not like I was preventing others from getting a table, and I did buy lunch there. I no longer feel guilty about using their internet, now I'm just annoyed. If I do become a coffeehouse study-er, I don't think I'll be going to Panera very often.

2. Public places are more distracting. While I've been here so far, this guy has been interviewing for a nanny for his kids, I think. I've tried not to totally eavesdrop (mostly because I have work to do), but what I've heard sounds like an interview. And the girl who was just here was dressed in jeans and a sweatshirt--what's that about? I mean, it's probably a more laid back interview than some, especially since the guy was wearing casual clothes, too, but come on. I'd think she'd try harder than that.

3. I feel self-conscious studying in front of a bunch of other people. When I do weird stuff like chew on my pen or play with my hair, I worry that people are looking at me. Even though people can see me when I study in the library, too, it seems a bit more private because people aren't constantly coming in and out. Plus, in the library, most other people are studying, too, so I figure they wouldn't likely notice if I was doing something strange.

On the plus side, getting out of the library increases the chance of seeing other people, making me feel like less of a hermit. For example, while I was studying, a guy near me noticed my Step 1 books, and started chatting with me about Boards. He's an MD/PhD who just finished his PhD, so he is joining our class next year on rotations. He gave me some tips about studying, though I'm not sure I can trust him, since I kind of got the feeling that he's one of those super-genius med students. He said that when he took the Boards a few years ago, he moved up his test date to only 2 weeks after he started studying, and still did well. Ostensibly, this was his way of saying not to worry too much, but come on, dude. That would be like me taking the test this week. No way I'd be ready.

But still, it's nice to talk to new people. So maybe the trip out was a good idea. :)

The Med Student Game

A couple weeks ago, I had a series of small group classes intended to teach Psychiatric interviewing skills. As part of the assignment, we had to interview a patient with a Psych issue, and write a formal note about the information we got from the interview. We have to write patient notes fairly often, but this one was a different format than I was used to, so it took a little extra effort (though they were nice enough to give us an example that we could copy from). After I did my interview and wrote my note, I emailed it to the Psychiatrist who led the group. A short time later, I got this email response from him:

Abby
you are both very good at playing the "med std game", that is making it easy for me to check off that you have done all parts of the required interview, and also you did a very nice interview--even though that is less a part of the formal scoring it is the most important of being a physician.
nice job

Every time I read this, I don't know quite what to think. The part about being good at the "med student game" gives me pause, because, while it's technically a compliment, I don't want to be the kind of student who just plays the game, and ignores the things that are actually important in learning to become a doctor. I'm pretty sure that's not what this doctor was saying, given the second part, complimenting my interview. Plus, this doc is the kind of guy who is enough of a pragmatist to know that we students have to play the game, at least to a certain extent.

But there are some people, I think, who only play the game, either because they don't want to worry about the actual important stuff, because they care so much more about grades and being "perfect", or because they don't have the skills to get through without "playing the game". I can't really say that these people are going about it the wrong way, because I certainly prioritize "the game" over learning for its own sake, like when I decide not to study a certain topic because I think it's unlikely to be tested, even though I can see how it might be important to practice someday. Med school is rough, and I'm not sure it's even possible to get through without learning to play the game well. So I guess I should be glad to hear that I'm good at it, but it is still an unexpected compliment.

A new chapter...

So, this blog has been pretty quiet lately, which was not intentional, but appears to have been an unavoidable side effect of second year medical school. I think it's probably more surprising that I managed to make a fair number of posts last semester than it is that I made almost none second semester.

But! The semester is finally over, and now that "summer" is here, I may actually have a bit more time for this. I don't really get a break in any meaningful sense of the word, as I am studying 40+ hours a week for my Board exam in a month, then I start my surgery rotation at the beginning of July. But this is much improved over last year, when I spent all morning and afternoon studying at school, only to come home and study a bit more before bedtime.

I don't want this blog to die off, because even though I haven't had much time for it, I still like the idea of track of this journey through medical school. Even if almost no one even knows it exists, hopefully I'll have some stories and insights over the course of my education that are meaningful to me. Someday, when I'm a happy doctor, looking back fondly on my med school days, I'll have a reminder of what things were really like.

My somewhat optimistic goal is one post per week, though I'm not sure if that will be manageable past July. But we'll see...

I think I'll end this post with a list of all the reasons why next year has to be better than the last two years. I've been told by several people that it will be, but I also thought that second year would be much better than first, and that didn't exactly go as planned. But maybe if I make a list, I'll be able to remember why the pre-clinical years were no fun, so I don't get too depressed with my crazy on-call schedule next year or whatever.

1. Patients! Finally, finally, finally, I will be able to stop spending every waking hour reading or thinking about reading about whatever random organ system. I mean, if course I'll still be looking things up and studying, but that should be nicely weighed out by getting to see and help real people (which is way better than the standardized patients that I had mostly been working with).

2. Individual attention. I didn't really think I'd mind that much, but I actually quite disliked not knowing my professors and having them not know who I was. Next year, there should be more opportunity to work more closely with Residents or Attendings or 4th years, or SOMEONE who will know who I am outside of the name on the top of the test. (Though I don't even think my current teachers had that, since our tests are computerized.)

3.Tests worth less than 50% of the course grade! This year especially, most of our tests were upwards of 60-70% of the total grade (and this is a single final exam, not two tests each worth 35% or something). That's stressful, having to worry so much about the single exam. And add to it the fact that most courses were curved, meaning there was no set grading scale and so no way to anticipate how well you needed to do to get whatever grade. Instead, I just had to hope that I studied harder than most of the rest of the class. In med school, that's less likely than it might have been at other points in my life.

4. Showing off clinical skills. I've generally gotten good feedback from instructors in my Doctoring class, saying that I do a good job working with patients. But that hasn't meant that much up to this point, as basically anyone who can talk coherently to a patient gets an A in Doctoring, so I didn't really have anything to show for it. But next year, this is a much bigger deal and a bigger part of our grades, so I'm hoping it will give me an advantage.

I'm sure there are more, but it's just about time to start getting ready for bed, so maybe I'll continue the list in a later post. Either way, this already has me looking forward to July. Let's hope I'm not deceiving myself!

You say you want a resolution...ye-ah, you know...

I've never really been the kind of person to make New Year's resolutions. I don't know, I guess there just aren't a lot of things in my life that I really want to change. Not that I'm perfect, of course, just that the things I'd like to be different aren't really that easy to make a resolution about. Plus, it always seems like a silly construct: what's so special about Jan 1 that makes it the day to start making changes?

But last year, I sort of accidentally made a couple New Year's resolutions. I never really thought about it as "These are my resolutions," but near the beginning of last year I decided to try to make some changes. Namely, excerise more and eat more fruits and veggies.

I'm not exactly sure what prompted that, actually. A combination of factors, it seems. First semester of Med School was behind me, so I felt like I had a handle on the coming semester and could manage to make some changes. Plus, the curriculum is full of reminders about how important diet and exercise is to health, and I began to feel that, if I was going to counsel patients on losing weight, I'd better be able to do some of those things myself. And, annoyingly, my BMI was just in the "Overweight" range, which was frustrating. I never considered myself overweight, and still think that BMI is not an exact science and I might have been one of the people it didn't quite apply to. But I also didn't want to be one of the people who just makes excuses, so I wanted to try to get that BMI down into the normal range.

I don't actually remeber making a plan, but I ended up with what turned out to be a pretty good one. Rather than try to super-diet and drop the weight (which was really only about 5 lbs) really quick, I figured it would be better if I started slow. You know, so I'd have some chance of making it stick.

So I decided to try to go to the Nat and swim one day every week for the whole semester. And when it got tough to wake up at 6:30 am in the dark of winter and drag myself across campus, I told myself it was okay to do an easy workout, because it wasn't about the intensity, it was about just doing any exercise.

And it worked! Every week last semester, I went to swim (except for maybe once when I was sick--sleep was more important). I kind of fell apart over the summer, but last semester, I kicked it up to two days a week. (Though now I'm just working out in my apartment's weight room, not the Nat, because it takes less time out of my much fuller schedule--but it's not about the activity, it's just about doing something.) And, with one week under my belt this semester, I am aiming for three times a week. (And I think I can do it!)

Plus, I also got myself up to 5 fruits and vegetables every day. This took a little more planning, but I've managed to work in more plants to my diet--carrots for snaking, broccoli with my pasta, etc.

With all this, my BMI is now safely in the "Normal Weight" range, which I am proud of. I'm going to keep at it, though, because even if I don't need to lose more weight, exercise is good!

Lifestyle change like this is interesting to me. If I had thought about exercising 3 days a week at the beginning of med school, I would have thought it was impossible. But even with my much busier current schedule, I'm pretty sure I can do it. I think the key is baby steps, really. It sounds kind of cheesy, I guess, but it works.

I'm starting to see that this idea is catching on, too. I've heard some ads for the smallstep.gov website that's supposed to help give people ideas about little changes they can make (though I'm not sure how useful it actually is--a lot of their suggestions aren't really that small). Plus more and more of my classes and clinical preceptors are mentioning this idea when talking about counseling patients. I hope it keeps spreading, and not just with medical types. It seems like most people who need to make lifestyle changes don't even realize some of the easy things they could be doing differently. If we could get everyone to take just a couple of those small steps, I think health would improve in general.

It was only a matter of time....

I think I just became a coffee-drinker.

For the first 23 years of my life, I never drank coffee, minus the occasional sip at a wedding or other occasion (followed by dislike of the taste and continued non-consumption). But this year, as med school continues unrelentingly, I began to think it was time I learned to like coffee. So far, I've been able to maintain my 8 hours of sleep nearly every night, but there are still days that I feel sleepy and in need of caffiene. Plus, I know my future holds many a night of on-call or other long shifts, so I doubted I'd be able to handle that lifestyle with caffiene from tea or Coke alone, as I had done so far.

So a couple of months ago, I bought a cup of coffee at the coffee cart at school, on a day when I was literally falling asleep in lecture. And I choked down about one-third of it (black, because I don't want the hassle or calories of cream and sugar). ANd, again, about a month or so after that, I bought another cup on an afternoon when I was tired and having trouble focusing. Both times, the coffee had the desired effect, and kept me up, but I really didn't like it.

But today...I got another cup, and I actually enjoyed the taste. I mean, it's not my favorite thing in the world (that would be chocolate), but I've finished almost the whole cup, and I really don't mind it at all.

Check. One more milestone on the road to becoming a doctor achieved.